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CORNELL UNIVERSITY. 



THE 
THE GIFT OF 

ROSWELL P. FLOWER 

FOR THE USE OF 

THE N. Y. STATE VETERINARY COLLEGE. 

1897 



CORNELL UNIVERSITY LIBRARY 



924 104 225 747 




The original of this book is in 
the Cornell University Library. 

There are no known copyright restrictions in 
the United States on the use of the text. 



http://archive.org/details/cu31924104225747 



LIST OF AUTHORS IN VOL. IL 



DENNIS, FREDERIC S., M. D. ; 
FORWOOD, WILLIAM H., M.D.; 
FOWLER, GEORGE R., M. D. ; 
GERRISH, FREDERIC H., M.D.; 
GIBNEY, VIRGIL P., M.D.; 
KEEN, W. W., M.D., LL.D; 
PARK, ROSWELL, M. D. ; 
ROBERTS, JOHN B., M.D.; 
SENN, NICHOLAS, M. D., LL.D., 
STIMSON, LEWIS A., M.D.; 
WHARTON, HENRY R., M.D. 



SYSTEM 



J\r^ M 



SURGERY. 




EDITED BY 

FEEDEEIC S. DENNIS, M.D., 

Pbofessoe of the Principlks and Peactice of Subgeey, Bellevue Hospital Medical College ; 

Visiting Surgeon to the Bellevue and St. Vincent Hospitals ; Consulting Suegeon to 

the Harlem Hospital and the Montefioee Home, New York; President of 

THE American Suegical Association; Geaduate op the Royal 

College op Surgeons, London ; Member op the German 

Congress of Surgeons, Berlin. 

ASSISTED BY 

JOHN S. BILLINGS, M. D.; 

LL.D. Edin. and Haev, ; D. C. L, OxoN. ; Deputy Subgeon-geneeal U. S. A. 



Vol. II. 



MINOR, PLASTIC, AND MILITARY SURGERY-DISEASES OF THE 
BONES-ORTHOP^DlC SURGERY- ANEURYSM- SURGERY 
OF THE ARTERIES, VEINS AND LYMPHATICS -DIS- 
EASES AND INJURIES OF THE HEAD- SURGERY 
OF THE SPINE-SURGERY OF THE NERVES. 



PROFUSELY ILLUSTRATED. 




PHILADELPHIA: 
LEA BEOTHEES & CO. 

1895. 



fisS^lTJ? 



Entered according to Act of Congress in the year 1895, by 

LEA BROTHERS & CO., 

in the Office of the Librarian of Congress, at Washington. All rights reserved. 



WESTCOTT i THOMSON, 
ELECTROTVPERS, PHILADA. 



2/ 



5i-V©rcL2Kv?^ 



PRESS OF 
WILLIAM J. DORNAN. PHILADA. 



CONTENTS OF VOLUME 11. 



PAGE 

MINOE SURGEEY . . ... 17 

By Henby E. Whaeton, M. D., Demonstrator of Surgery and Lecturer on 
the Surgical Diseases of Children, University of Pennsylvania, Philadelphia. 

PLASTIC SUEGEEY . . . . . .137 

By George E. Fowler, M. D., Surgeon to St. Mary's and the Methodist 
Episcopal Hospitals ; Examiner in Surgery to the State Medical Exam- 
ining Board, Brooklyn. 

MILITAEY SUBGEEY AND THE CAEE OP THE WOUNDED ON THE 

BATTLE-FIELD 191 

By "William H. Foewood, M. D., Lieutenafit-Colonel and Deputy Surgeon- 
General, U. S. A. ; Professor of Surgery in the Army Medical School, 
Washington, D. C. 

DISEASES OF THE BONES . . . 219 

By Nicholas Seistn, M. D., LL.D., Professor of the Practice of Surgery, 
Eush Medical College ; Professor of Surgery, Chicago Polyclinic ; Surgeon 
to the Presbyterian and Emergency Hospitals, Chicago. 

ORTHOPEDIC SUEGEEY . 265 

By Virgil P. Gibney, M. D., Surgeon-in-Chief to the Hospital for Eup- 
tured and Crippled ; Orthopsedic Surgeon to the Nursery and Child' s Hos- 
pital, New Yorlf. 

ANEUEYSM . ... ... . . . . 367 

By Lewis A. Stimson, M. D., Professor of Surgery, University of the City of 
New York ; Surgeon to the Bellevue and New York Hospitals, New York. 

SUEGEEY OF THE AETEEIES AND VEINS (EXCLUSIVE OF 

ANEUEYSM) . . . .435 

By Frederic S. Dennis, M. D., Professor of the Principles and Practice of 
Surgery, Bellevue Hospital Medical College ; Surgeon to the Bellevue and 
St. Vincent Hospitals, New York. 

7 



8 CONTENTS. 

PAGE 

SURGERY OF THE LYMPHATIC SYSTEM 461 

By Pbedekic H. Gekkish, M. D., Consulting Surgeon, Maine General Hos- 
pital, Portland, Me. ; Professor of Anatomy, Bowdoin College. 

DISEASES AND INJURIES OF THE HEAD . . 497 

By Roswell Paek, M. D., Professor of Surgery, Medical Department Uni- 
versity of Buffalo ; Surgeon to the Buffalo General Hospital, and Consulting 
Surgeon to the Fitch Accident Hospital, Buffalo, N. Y. 

THE SURGERY OF THE SPINE . . 787 

By W. W. Keen, M. D., LL.D., Professor of the Principles of Surgery and 
of Clinical Surgery, Jefferson Medical College, Philadelphia. 

SURGERY OF THE NERVES . 867 

By John B. Roberts, M. D., Professor of the Principles and Practice of 
Surgerj', Woman's Medical College, Philadelphia. 



MINOR SURGERY. 

By HENBY E. WHARTON, M. D. 



Bandages. 



Bandages constitute one of the most widely used and important 
surgical dressings : they are very generally employed to hold dressings 
in contact with wounds, to make pressure, and to secure splints in place 
in the treatment of fractures and dislocations. Bandages may be pre- 
pared of various materials, such as muslin (bleached or unbleached), 
linen, crinoline, flannel, cheese- or tobacco-cloth, rubber sheeting ; and 
of these the most widely used is the bandage made from unbleached 
muslin, because of its cheapness. Flannel, from its elasticity, is some- 
times used, but its employment for bandages is now generally limited 
to its use in dressings after operative work upon the eye and for the 
primary roller in the application of plaster-of-Paris dressings. 

Bandages are either simple, when composed of one piece of material, 
such as the ordinary roller bandage, or compound, when prepared of one 
or more pieces secured together and adapted by size and shape to pecu- 
liar objects. Every practitioner should be perfectly familiar with the 
general rules of bandaging, and proficient in the application of the roller 
bandage, for a well-applied bandage adds much to the comfort of the 
patient, and the method of its application often secures for the physician 
the confidence both of the patient and his friends, while, on the other 
hand, a badly-applied bandage is apt to be uncomfortable and insecure. 

The Roller Bandage. — The roller bandage consists of a strip of 
some one of the materials previously mentioned, of variable length and 
width, which, for ease of application, is rolled into a cylindrical form. 
A bandage rolled into the form of a cylinder is called a single or single- 
headed roller ; if rolled from each extremity toward the centre, so that 
two cylinders are formed, joined by a central strip, a double or double- 
headed roller is formed. Double rollers are not much used at the 
present time, and in practice the single roller will be found to be amply 
sufficient for the application of almost all the bandages employed in 
surgical dressings. The free end of the roller bandage is called the 
initial extremity ; the end which is enclosed in the centre of the cylinder 
is the terminal extremity; and the portion between the extremities, the 
body. The roller bandage has two surfaces, external and internal. The 
material commonly employed for the roller bandage is unbleached 
muslin, although for special purposes linen, flannel, rubber sheeting, 
crinoline, or cheese-cloth may be used. It is important that the roller 
bandage should consist of one piece, free from seams or selvage, for if 
made from a number of pieces sewed together, or if it contains creases 
Vol. II.— 2 17 




18 MINOR SUBGEBY. 

or selvage, it cannot be so neatly applied and it is not so comfortable to 
the patient, as it is apt to leave creases upon the skin. In preparmg 
the ordinary muslin bandage the material is torn into strips varying in 
length and width according to the portion of the body to which it is 
to be applied, and it is then rolled into a cylinder, either by hand or 
by a machine constructed for the purpose. 

Every practitioner should be able to roll a bandage by hand, tor 
in practice the medical attendant may at any moment be called upon 

to roll a bandage in order to apply 
Fig. 1. dressing, and the art is acquired by 

a little practice. To roll a bandage 
by hand the strip should be folded 
at one extremity several times until 
a small cylinder is formed; this is 
then grasped by its extremities by the 
thumb and index finger of the left 
hand ; the free extremity of the strip 
is then grasped by the thumb and 
index finger of the right hand, and 
by alternating pronation and supina- 
tion of the right hand the cylinder is 
revolved and the roller is formed : the 

firmness of the roller will depend 

"Rolling a bandTge by hand. upoQ the amount of tension which is 

kept upon the free extremity of the 
strip during the revolution ot the cylinder (Fig. 1). 

Dimensions of Bandages. 

Bandages vary in length and width according to the purposes for 
which they are employed, and in practice it will be found that a 
small variety of bandages will be amply sufficient for the application 
of all the ordinary surgical dressings. The following list comprises 
those most frequently used, and shows their dimensions : 

Bandage one inch in width, three yards in length, for bandage for 
hand, fingers, and toes. 

Bandage two inches wide, six yards in length, for head bandages and 
for the extremities in children. 

Bandage two and a half inches wide, seven yards in length, for 
bandages of the extremities in adults ; a roller of this size is the one 
most generally used. 

Bandage three inches wide, nine yards in length, for bandages of the 
thigh, groin^ and trunk. 

Bandage four inches wide, ten yards in length, for bandages of the 
trunk. 

General Rules foe Bandaging. 

In applying a roller bandage the operator should place the external 
surface of the free extremity of the roller on the part, and hold it in 
position with the fingers of the left hand until fixed by a few turns of 
the roller, the cylinder being held in the right hand, so that, as the 



BANDAGES. 



19 



bandage is unwound it rolls in the operator's hand, thereby giving him 
more control of it ; care should also be taken that the turns are applied 
smoothly to the surface and that the pressure exerted by each turn is 
uniform. When a bandage is applied to a limb the surgeon should see 
that the limb is in the position that it should occupy, as regards flexion 
and extension, when the dressing is completed, for a bandage applied 
when the limb is flexed will exert too much pressure when the limb is 
extended, and may thus become a matter of discomfort or even of 
danger to the patient, or if applied to an extended limb it will become 
uncomfortable upon flexion. Those who have little experience in the 
application of roller bandages are apt to apply their bandages too 
tightly, and this may lead to disastrous consequences, especially in the 
dressing of fractures. When the bandage has been completed the 
terminal extremity should be secured by a pin or safety-pin applied 
transversely to the bandage, and if a pin be used its point should be 
buried in the folds of the bandage ; or if the bandage be a narrow one 
the end may be split, and the two tails resulting may be secured 
around the part by tying. In removing a bandage the folds should be 
carefully gathered up into a loose mass as the bandage is unwound, the 
mass being transferred rapidly from one hand to the other, thus facil- 



FiG. 2. 




Method of removing a bandage. 

itating its removal and preventing the part becoming entangled in its 
loops (Fig. 2). 

Varieties of Bandages. 

The Circular Bandage. — This bandage consists of a few circular 
turns around a part, each turn covering accurately the preceding turn 
(Fig. 429, b). This variety of bandage may be used to retain a dress- 
ing to a portion of the head, neck, or limbs, or to hold a compress upon 
the veins of the extremities in the case of wounds or before or after 
performing venesection. 



20 



MIXOR SURGERY. 



The ObliQue Bandage.— In this form of bandaging the turns are 
carrld obHquely fver th^e parts, leaving uncovered spaces between the 




Oblique bandage. 

successive turns (Fig. 3). Its principal use is for securing temporarjr 

"^"^The^Spiral Bandage.— In this bandage the turns are carried around 
the parts in a spiral direction, each turn overlapping the previous one 
usually one-third or one-half; it may be applied as an ascending spiral 

Fig. 4. 




Ascending spiral bandage. 

(Fig. 4) or as a descending spiral (Fig. 5). This bandage may be 



Fig. 5. 




Descending spiral bandage. 

used to cover a part which does not increase too rapidly in diameter ; for 
instance, the abdomen, chest, or arm. 

The Spiral Reversed Bandage. — This bandage is a spiral bandage, 
but diifers from the ordinary spiral bandage in having its turns folded 
back or reversed as it ascends a part the diameter of which gradually 
increases. By its use it is possible to cover by spiral turns a part conical 
in shape, so as to make equable pressure upon all parts of the surface. 



BANDAGES. 



21 



The reverses are made as follows : After fixing the initial extremity of 
the roller, as the part increases in diameter the bandage is carried off a 
little obliquely to the axis of the limb from three to six inches ; the index 
finger or thumb of the disengaged hand is placed upon the body of the 
bandage to keep it securely in place upon the limb ; the hand holding 
the roller is carried a little toward the limb to slacken the unwound por- 
tion of the bandage, and by changing the position of the hand holding 
the bandage from extreme supination to pronation the reverse is made 
(Fig. 6). Care should be taken not to attempt to make the reverse 
while the bandage is tense, for by so 

doing the bandage is twisted into a Fig; 6. 

cord which is unsightly and uncom- 
fortable to the patient, instead of 
forming a closely - fitting reverse. 
The reverse should be completed 
before the bandage is carried around 
the limb, and when it has been com- 
pleted the bandage should be slightly 
tightened, so as to conform to the 
part accurately. The reverses should 
be in line, to have the bandage pre- 
sent a good appearance, and care 
should be taken that the reverses 
are not made over salient parts of 
the skeleton, for if they occupy such 
position they cause creases of the 
skin and become uncomfortable to 
the patient. To make reverses neatly 
and have them in line requires skill and practice ; a well-applied spiral 
reversed bandage is a test of a competent bandager. 

The Spica Bandag-e. — When the turns of the roller cross each other 
in the form of the Greek letter lambda, leaving the previous turn about 
one-third uncovered, the bandage is known as a spica bandage (Fig. 7). 




Method of making reverses. 



Fig. 7. 




Spica bandage. 



Circular bandage. 



The spica bandages are especially serviceable as a means of retaining 
surgical dressings upon the shoulders, groin, or foot. 

Figure-of-8 Bandage. — This bandage receives its name from the 
turns being applied so as to form the figure of 8. This method of appli- 
cation is made use of in the Barton bandage, the bandages of the knee 
and elbow, and many other bandages. 



22 



MINOR SURGERY. 




Kecurrent bandage. 



Recurrent Bandage.— This bandage derives its name from the fact 
that the roller after covering a certain portion of the surface is reflected 

and brought back to the point ot startmg ; 
Fig. 8. it is then reversed and carried toward the 

opposite point; and this manipulation is 
continued until the part is covered in 
by these recurrent turns, which are then 
secured by a few circular turns passed 
around the part (Fig. 8). This is the 
bandage usually employed in the dress- 
ings of stumps. 

Compound Bandages. — These band- 
ages are usually formed of several pieces 
of muslin or other material sewed or 
pinned together, and are employed to 
fulfil some special indication in the appli- 
cation of dressings to particular parts of 
the body. The most useful of the com- 
pound bandages are the T-bandages and 
the many-tailed bandages. 
T-Bandages. — The single T-bandage consists of a horizontal band, 
to which is attached, about its middle, another band in a vertical direc- 
tion : the horizontal piece should be twice the length of the vertical piece 

(Fig. 9). The single T-bandage 
FrG. 9. may be used to retain dressings to 

the head, the horizontal piece being 
passed around the head from the 
occiput to the forehead, the vertical 
piece being passed over the head 
and secured to the horizontal piece ; 
the shape and width of the two 
pieces being varied according to the 
indications. In applying dressings 
to the anal region or perineum, or 
in securing a catheter in a perineal 
wound, the single T-bandage will 
be found most useful. In applying 
a T-bandage for this purpose, the body of the bandage is placed over 
the spine just above the pelvis, and the horizontal portion is tied around 
the abdomen. The free extremity is split into two tails for about two- 
thirds of its length, and is carried over the anal region and brought up 
between the thighs, the terminal strips passing one on each side of the 
scrotum and being secured to the horizontal strip in front. The single 
T-bandage may be variously modified according to the indications which 
are to be met ; for instance, in applying a dressing to the breasts the 
horizontal strip passing around the chest may be made ten or twelve 
inches in width ; a vertical strip, two inches in width, passes from the 
back over the shoulder and is secured to the horizontal strip in front 
(Fig. 10). It may also be modified to apply dressings to particular 
parts of the body ; for instance, to the groin, in which case a piece of 
muslin six inches wide at its base and thirty-six inches long is sewed 




Single T-bandage. 



BANDAGES. 



23 



to a horizontal piece of muslin 
inches in width. It may 
be applied as in Fig. 11 to 
hold dressings to this part. 
Double T-bandage. — 
The double T-bandage dif- 
fers from the single T- 

FiG. 10. 



one and a half yards long and two 



Fig. 11. 





Single T-bandage for chest. 



T-baMage of gioin. 



bandage in having two vertical strips attached to the horizontal strip, 
and it may be used for much the same purpose as the single T-bandage. 
It may be conveniently used for retaining dressings to the chest, breasts, 
or abdomen ; when used for this purpose the horizontal portion should 
be from eight to ten inches wide, and long enough to pass one and a 
quarter times about the chest or abdomen ; two vertical strips, two inches 
wide and twenty inches long, should be attached to the horizontal strip 
a short distance apart, near its middle. In applying this bandage to the 
chest the horizontal strip is passed around the chest, so that the vertical 
strips occupy a position on either side of the spine ; the overlapping end 



Fig. 12. 



Fig. 13. 





Double T-bandage of chest. 



Double T-bandage of nose. 



of the horizontal portion is secured by pins or safety-pins, and the ver- 
tical strips are next carried, one over each shoulder, and secured to the 
other portion of the bandage in front of the chest (Fig. 12). The 



24 



MINOR SURGERY. 



double T-bandage may also be used to secure dressings to the nose, 
in which event the strips should be quite narrow, about one inch m 
width, and should be applied as shown in Fig. 13. 

Many-taHed Bandages or Slings.— These bandages are prepared 
from pieces of muslin, which are split at each extremity into two, three, 
or more tails up to within a few inches of their centres, their width and 
length being regulated by the part of the body to which they are to be 
applied. 

The four-tailed bandage may be found useful as a temporary dressing 
in cases of fracture of the jaw or to hold dressings to the chip. It niay 
be prepared by taking a portion of a roller bandage three inches wide 
and one yard in length, and splitting each extremity up to within two 
inches of the centre, and it is then applied as seen in Fig. 14. A four- 



FiG. 14. 



Fig. 15. 





Four-tailed bandage of chin. 



Four-tailed bandage of head. 



tailed bandage may also be used to retain dressings to the scalp, and can 
be prepared by taking a piece of muslin one and a quarter yards long 
and six or eight inches in width, splitting it at each extremity into two 
tails within six inches of the centre ; it may then be applied as seen in 
Fig. 15. A four-tailed bandage may also be used in the temporary 
dressing of fracture of the clavicle ; the body of the bandage being placed 
upon the elbow of the injured side, the two tails should be passed around 
the body and tied, fixing the arm to the side ; two tails should pass over 
the sound shoulder, and their ends should be secured by tying; ' 

The many-tailed bandage may also be used for holding dressings in 
contact with the abdomen or trunk, and this is the bandage which many 
surgeons employ to hold dressings to a laparotomy wound and to give 
support to the abdominal walls after this operation. In preparing this 
bandage a strip of muslin or flannel, one and a half yards in length and 
eighteen to twenty inches in width, is required ; the extremities may be 
split so as to form an eight-tailed bandage. In applying this bandage 
to the abdomen the body of the bandage is placed upon the patient's 
back, and the tails are brought around the abdomen and overlap each 
other, and when sufficiently firmly drawn to make the desired amount 
of pressure they are secured by means of safety-pins. 



BANDAGES. 25 

Handkerchief Bandages. — The use of handkerchiefs or square 
pieces of muslin for the temporary dressings of wounds, fracture, or dis- 
location was advocated many years ago by M. Mayor, a Swiss surgeon, 
who wrote an extensive work upon this subject. He employed a hand- 
kerchief or a square piece of muslin, and by various modifications in the 
application of these developed a number of very ingenious bandages in 
which the handkerchief or square may be used as an oblong, made by 
folding the square once or twice on itself; as a triangle, made by bring- 
ing together the diagonal angles of the square ; or as a cravat or cord. 

The names of the various handkerchief bandages are derived from 
the shape of the handkerchiefs used and the parts to which they are to be 
applied ; the names also serve as guides to their application. It is to be 
remembered that the base of the triangle or the body of the cravat is to 
be placed upon the portion the designation of which forms the first 
portion of the name of the bandage ; thus, in the fronto-occipital triangle 
the shape of the handkerchief is given, and we know that the base of 
the triangle is to be applied to the forehead and then passed to the occi- 
put. In using the cravat the same rule applies ; thus, in the bis-axillary 
cravat the body of the cravat is placed in the axilla of the affected side, 
the extremities cross over the corresponding shoulder, and are carried 
over the chest, one before, the other behind, to the axilla of the opposite 
side, where they are secured. 

The following are a few of the many ingenious bandages devised by 
Mayor as substitutes for the roller bandage. It is well to bear in mind 

Fig. 16. 



Occipito-frontal triangle. 



this system of dressing : the occasion may occur in which other means 
of bandaging could not be obtained, and the application of handkerchief 
bandages might answer a useful purpose for temporary dressings, but 
they will never take the place of the roller bandage, which can be 



26 MINOR SUBQEBY. 

applied with much greater nicety and exactness and certainly presents a 
much neater appearance. x.- e ^ „+u^ 

The Ocdpito-frontal Triangle.— To apply this handkerchief, place the 
base of the triangle on the nape of the neck and bring the apex forward 
over the head, allowing it to hang down in front; knot the extremities 
around the forehead, and turn up the apex over the knot and pm it 

to the body (Fig. 16). i,- j> j.u 

Mento-vertioo-occipital Cravat— In applying this handkerchiet the 
middle of the base of the cravat is placed under the chm, the extrem- 
ities are then carried to the vertex of the skull and are crossed at that 
point, and the ends are carried down over the parietal region and secured 
by a knot at the occiput (Fig. 17). Another method of applying this 

Fig. 17. 




Mento-vertlco-occlpital cravat. 

cravat consists in placing the base of the cravat under the chin and 
carrying the extremities over the vertex, crossing them at that point, 
then carrying them downward to the occiput, crossing them at this 
point, and passing them forward around the front portion of the chin 
and securing the ends by a knot. The turns of the cravat correspond 
exactly to those of the Barton bandage for the head, and this dressing, 
as well as the mento-vertico-occipital cravat previously described, may 
be used as a temporary dressing to secure fixation in cases of fracture 
of the upper or lower jaw (Fig. 18). 

The Bis-axillary Cravat. — The body of the cravat is placed in the 
axilla and the ends are brought up, one in front and one behind the 
axilla, and are made to cross over the shoulder; the extremities are 
then carried across the chest and back respectively to the opposite 
axilla, where they are secured by tying. This handkerchief may be 
used to secure dressings in the axilla or to hold dressings to the shoulder 
(Fig. 19). 



BANDAGES. 



27 



The Dorso-axillary Cravat. — This handkerchief is applied by placing 
the body of the cravat upon the spine, and carrying one extremity over 
the shoulder and through the axilla backward to meet the other extrem- 



FiG. 18. 




llento-vertico-occipital cravat modified. 



ity, which has been carried through the axilla and over the other 
shoulder to the back, where the ends are secured. This handkerchief 



Fig. 19. 




Bis-axillary cravat. 



may be made to hold dressings to the axilla or to the upper portion 
of the back (Fig. 20). 

The Triangular Cap or Suspensory of the Breast. — The base of the 



28 



MINOR SURGERY. 



handkerchief, folded into a triangle, is placed over the affected breast, 
and one end is carried beneath the axilla, and the other end is conducted 
around the opposite side of the neck to be tied together on the back ; 



Fig. 20. 




Dorso-axiUary cravat. 



the apex should then be brought up and passed over the shoulder of the 
affected side and fastened to the bandage behind (Fig. 21). This hand- 



FiG. 21. 




Triangular cap or suspensory of the breast. 



kerchief is a convenient method of slinging the breast in nursing women 
or holding a dressing to the breast. 



BANDAGES. 29 

Uio-femoral Triangle. — In applying this handkerchief a long cravat 
is fastened around the waist ; the base of the triangle is then placed in 
the gluteo-femoral fold, and its extremities are fastened around the thigh, 
and the apex is carried up and passed beneath the cravat around the 
waist, and is turned down and pinned to the body of the triangle (Fig. 
22). This handkerchief may be used to retain dressings to the region 

Fig. 22. 




Tlio-femoral triangle. 

of the buttock, hip, or groin : by unpinning the apex and turning it 
down ready access can be had to the parts beneath without disturbing 
the patient. 

Bandages of the Head and Neck. 

Barton's Bandage. — Roller two inches in width, six yards in length. — 
Application. — The initial extremity of the roller should be placed on 
the head just behind the mastoid process, and the bandage should then 
be carried under the occipital protuberance obliquely upward, and under 
and in front of the parietal eminence across the vertex of the skull, then 
downward over the zygomatic arch, under the chin, thence upward over 
the opposite zygomatic arch and over the top of the head, crossing the 
first turn, which was made as nearly as possible in the median line of the 
skull, then carry the roller under the parietal eminence to the point of 
starting. The bandage is then passed obliquely around under the occipi- 
tal protuberance and forward under the ear to the front of the chin, thence 
back to the point from which the roller started. These figure-of-8 turns 
over the head and the circular turns over the occiput to the chin should 
be repeated, each turn exactly overlapping the preceding one until the 
bandage is exhausted (Fig. 23). The extremities should then be secured 
by a pin, and pins should be introduced at the points where the turns, 



30 MINOS. SUBGEBY. 

cross each other to give additional fixation to the bandage. In applying 
the bandage care should be taken to see that the turns overlap each other 

Fig. 23. 




Barton's bandage. 



exactly, and that the turns passing over the vertex cross as near as pos- 
sible in the median line of the skull. 



Fig. 24. 




Modified Barton's bandage. 



Modfed Barton's Bandage.— To obtain additional security in the 
application of the Barton bandage a turn of the bandage passing from the 



BANDAGES. 31 

occiput to the forehead may be made, this turn being interposed between 
the turns of the bandage as ordinarily applied (Fig. 24). In applying 
this bandage, after the first set of turns has been completed — that is, 
after the bandage has been brought back to the occiput— the bandage is 
carried forward upon the head just over the ear, around the forehead, 
and backward above the ear on the opposite side of the 'occiput ; this 
being done, the ordinary figure-of-8 and circular turns are made, and 
when these have been completed another occipito-frontal turn may be 
made as described above, and this may be repeated as often as is desired 
until the bandage is exhausted, when the extremity is fastened with a 
pin, and pins are also introduced at all points at which the turns cross. 

Use. — This is one of the most useful of the bandages of the head, 
being employed to secure fixation to the jaw in cases of fracture or dis- 
location, and for the application of dressings to the chin. It may also be 
employed in slinging patients for the application of a plaster-of-Paris 
bandage in cases of disease of the spine, a stout cord or a piece of band- 
age three inches in width and one yard long being passed under the turns 
passing over the vertex ; this cord is then secured to the cross-bar of the 
extension apparatus ; and this will be found as comfortable to the patient 
as the ordinary head-gear employed, and much less likely to slip out of 
place and interfere with the breathing of the patient. 

Gibson's Bandage. — Roller two inches in width, six yards in length. — 
Application. — The initial extremity of the roller should be placed upon 
the vertex of the skull on a line with the anterior portion of the ear ; 
the bandage is then carried downward in front of the ear to the chin, 
and passed under the chin, and is carried upward on the same line until 
it reaches the point of starting. The same turns are repeated until three 
complete sets of turns have been made ; the bandage is then continued 
until it reaches a point just above the ear, when it is reversed and is car- 
ried backward around the occiput, and is continued round the head and 
forehead until it reaches its point of origin ; these circular turns are 
repeated until three turns have been made. When the bandage reaches 
the occiput, having completed these three 
turns, it is allowed to drop down to the I^'t"- 25. 
base of the skull, and it is then carried 
forward below the ear and around the 
chin, being brought back upon the op- 
posite side of the head and neck to the 
point of origin. These turns are repeated 
until three complete turns have been 
made, and upon the completion of these 
turns the bandage is reversed and carried 
forward over the occiput and vertex to 
the forehead, and its extremity is here 
secured by a pin; pins should also be 
applied where the turns of the bandage 
cross each other (Fig. 25). 

Use. — This bandage may be used to Gibsons bandage. 

fix the lower jaw in cases of fracture 

or dislocation of the jaw, but is very apt to change its position, and is 
therefore not so satisfactory as the Barton bandage for this purpose. 




32 



MINOR SUBGERT. 



Fig. 26. 



Oblique Bandage of the Angle of the Jaw. — Roller two inches in 
width, six yards in length. — Application'. — The initial extremity of the 
roller is placed just in front of and above the left ear, and if the left 
angle of the jaw is to be covered in, the bandage is to be carried from 
left to right, making two complete turns around the cranium from the 
occiput to the forehead. If, however, the right angle of the lower jaw 
is to be covered in, the turns should be made in the opposite direction. 
Having made two turns from the occiput to the forehead, the bandage is 
allowed to drop down upon the neck, and is carried forward under the 
ear and under the chin to the angle of the jaw ; it is now carried upward 
close to the edge of the orbit and obliquely over the vertex of the skull, 
then do^vn behind the right ear, continuing these oblique turns under 

the chin to the angle of the left jaw, where 
it ascends in the same direction as the pre- 
vious turn. Three or four of these oblique 
turns are made, each turn overlapping the 
preceding one and passing from the edge 
of the orbit toward the ear until the space 
is covered in ; the bandage is then carried 
to the point just above the ear on the op- 
posite side, is reversed, and finished with 
one or two circular turns from the occiput 
to the forehead, the extremity being secured 
by a pin (Fig. 26). 

UsE.^-This is one of the most useful of 
the head bandages ; it may be used with a 
compress in treating fractures of the angle 

Oblique bandage of angle of the jaw. ^^ ^]^^ ^O^'ei" J^W, for holding dressings tO 

the lower part of the chin and to the vault 
of the cranium, and it is especially useful in retaining dressings to the 
sides of the face and the parotid region. It may be applied to cover 
either the right or left side of the face, and holds its position most 

securely, having little tendency to become 
displaced. 

Recurrent Bandage of the Head. — 
Roller two inches in width, six yards in 
length. — Application. — The initial extrem- 
ity of the roller is placed upon the lower 
part of the forehead, and the bandage is 
carried twice around the head from the fore- 
head to the occiput to secure it. When the 
bandage is brought back to the median line of 
the forehead it is reversed, and the reversed 
turn is held by the finger of the left hand 
while the roller is carried over the top of the 
head along the sagittal suture to a point just 
below the occipital protuberance ; here it is 
reversed again, and the reverse is held by an 
assistant while the roller is carried back to 
, . , ^"6 forehead in an elliptical course each turn 

covering in two-thirds of the preceding turn. These turns ak repeated 




Fig. 27. 




Recurrent bandage of the head. 



BANDAGES. 33 

with successive reverses at the forehead and occiput until one side of the 
head is completely covered in, and when this is accomplished a circular 
turn is made from the forehead to the occiput to hold the reverses in 
place. The opposite side of the head is next covered in by elliptical 
reversed turns made in the same manner, and when this has been accom- 
plished two or three circular turns are carried around the head from the 
forehead to the occiput to fix the previous turns. Pins should be applied 
at the forehead and occiput at the points where the reversed turns con- 
centrate (Fig. 27). 

Use. — This bandage when well applied is one of the neatest of the 
head bandages, and is useful to retain dressings to the vault of the cra- 
nium in the treatment of wounds of the scalp in this region ; also in 
holding dressings to fractures of the cranium and to wounds after the 
operation of trephining. In restless patients it will sometimes become 
displaced, and it may be rendered more secure by pinning a strip of 
bandage to the circular turn in front of the ear and carrying it down 
under the chin and up to a corresponding point on the opposite side, 
where it is pinned to the circular turn ; or one or two oblique turns, pass- 
ing from the circular turn over the vertex of the skull downward behind 
the ear, under the chin and up to the circular turn in front of the ear, 
may be applied. The course of these turns is the same as those applied 
in the oblique bandage of the angle of the jaw, the extremity being 
secured by a pin. 

Transverse Recurrent Bandage of Head. — Roller two inches in 
width, six yards in length. — Applicatiox. — The initial extremity of the 
roller i is placed upon the lower part of 
the forehead, and the bandage is carried 
twice around the head from the forehead 
to the occiput to secure it. The head is 
then covered in by transverse turns of 
the bandage : the first turn, starting from 
a point behind the ear on one side, is 
carried below the occiput to a corre- 
sponding point behind the opposite ear, 
and ascending transverse turns are then 
made and carried over the head, each 
turn covering in about two-thirds of the 
preceding turn, until the forehead is 
reached, and when this has been reached 
two or three circular turns are carried 

around the head from the forehead to the Transverse recurrent bandage of head. 

occiput to fix the recurrent turns. Pins 

should be applied at the point of starting of the reversed turns behind 

the ears, and at the occiput and forehead (Fig. 28). 

Use.— This bandage is used for the same purposes as the recurrent 
bandage of the head. 

V-Bandage of the Head. — Roller two inches in width, four yards in 
length. — Application. — The initial extremity of the roller is secured 
by two turns of the bandage around the cranium from the forehead to 
the occiput, and when the roller reaches the occipital protuberance it is 
allowed to drop slightly, a little below this, and is carried forward below 

Vol. II.— .H 




34 



MINOR 8UBGEBT. 



the ear around the front of the chin and lower lip ; it is then conducted 
backward to the point of starting. These turns, passing from the 
occiput to the forehead and from the occiput to the chm, are alter- 
nately made until a sufficient number have been applied, and the 
extremity is secured by a pin over the occiput (Fig. 29). 

This bandage may be modified by carrying the turns from the occiput 
forward under the ear and around the upper lip and back to the occi- 
put, and alternating these turns with the occipito-frontal turns; if 
employed in this way, a bandage one and a half inches in mdth should 
be used. 

Use. — This bandage may be employed to hold dressings to the front 
of the chin, to the upper and lower lips in cases of wounds, or to give 
support to these parts after plastic operations. 



Fig. 29. 



Fig. 30. 





V-bandage of the head. 



Head-and-neek bandage. 



Head-and-neck Bandage. — Roller two inches in width, four 
yards in length. — Application. — The initial extremity of the roller 
is placed upon the forehead and carried backward just above the ear to 
the occiput, and is then brought forward around the opposite side of the 
head to the point of starting. Two of these circular turns are made 
to fix the bandage, and when it is carried back to the occiput it is 
allowed to drop down slightly upon the neck, and is then carried around 
the neck, the turns around the head alternating with the neck turns 
until a sufficient number of these have been applied, when the extremity 
of the bandage is secured by a pin at the point of the crossing of the 
turns at the back of the head (Fig. 30). 

Use. — This bandage may be found useful in securing dressings to 
the anterior or posterior portion of the neck or to the region of the 
occiput. 

Care should be taken to apply it in such a manner that too much 
pressure is not made by the turns around the neck, which would 
be uncomfortable to the patient, and might seriously interfere with 
respiration. 

Crossed Bandage of One Bye. — Roller two inches in width, four 
yards in length. — Application. — The initial extremity of the bandage 



BANDAGES. 



35 



Fig. 31. 




Crossed bandage of one eye. 



is placed upon the forehead, and fixed by two circular turns passing 

around the head from the occiput to the forehead ; the roller is then car- 
ried back to the occiput and passed around 

this and brought forward below the ear, and, 

passing over the outer border of the cheek, 

is carried upward to the junction of the nose 

with the forehead, and is then conducted 

over the parietal protuberance downward to 

the occiput ; a circular fronto-occipital turn 

is next made, and when the bandage is 

brought back to the occiput it is again 

brought forward to the cheek and ascends to 

the forehead, covering in two-thirds of the 

previous turn, and is again conducted back 

to the occiput ; these turns are repeated, tiie 

oblique turns covering the eye alternating 

with circular turns around the head until the 

eye is completely enclosed (Fig. 31), and 

the bandage is finished by making a circular turn about the head and 

introducing a pin to secure its extremity. It will be found more com- 
fortable to the patient to include the ear on the same side on which the 
eye is covered in the turns of the bandage. 

Use. — This bandage will be found useful in retaining dressings to 
one eye. It will be more comfortable to the patient if a flannel roller 
be used for this bandage as well as the bandage which includes both eyes. 
Crossed Bandage of Both Eyes. — Roller two inches in width, six 
yards in length. — Application. — The initial extremity of the roller is 
placed upon the forehead, and secured by two circular turns of the band- 
age passing around the head from the forehead to the occiput ; the roller 
is then carried downward behind the occiput and brought forward below 
the ear to the upper portion of the cheek ; it is then carried upward to 
the jimction of the nose with the forehead, and 
conducted over the parietal protuberance to the 
occiput ; a circular turn is now made around 
the head from the occiput to the forehead, and 
the roller is carried from the occiput over the 
parietal protuberance of the opposite side for- 
ward to the junction of the nose with the fore- 
head, then downward over the eye and outer 
portion of the cheek below the ear and back 
to the occiput; a circular turn around the 
head is next made, and this is followed by 
a repetition of the previous turns, ascend- 
ing over one eye, descending over the other 
eye, each turn alternating with a circular 
turn around the head. These turns are re- 
peated until both eyes are covered in, and 
the bandage is finished by making a cir- 
cular turn around the head, the extremity 
(Fig. 32). In this bandage both ears may 
uncovered. 




Crossed bandage of both eyes, 

secured by a 



being 
be covered m or 



pm 

left 



36 



MINOR SUBOEBY. 



Use. — This bandage may be used to apply dressings to both eyes, and 
both of these bandages covering the eyes are used where it is desired 
to make pressure ; but for the simple application of a light dressing 
or of a bandage for the exclusion of light the Liebreich's bandage will 
be found more comfortable to the patient. 

Occipito-facial Bandag-e. — Roller two inches in width, four yards in 
length. — The initial extremity of the roller is placed upon the vertex 
of the head, and the bandage is carried downward in front of the ear 
and under the jaw, and upward upon the opposite side in the same line 
to the vertex ; two or three of these turns are made, one turn accurately 
covering in the other, and a reverse is made just above and in front of 
the ear, and two or three turns are made around the head from the occi- 
put to the forehead, which completes the bandage (Fig. 33). Pins should 
be inserted at the points where the turns of the bandage cross each other. 

Use. — This bandage is employed to secure dressings to the vertex, 
or to the temporal, occipital, or frontal regions. 



Fig. 33. 



Fig. 34. 





Occipito-facial bandage. 



Oblique bandage of the head. 



Oblique Bandage of the Head. — Roller tivo inches in width, four 
yards in length. — The initial extremity of the bandage is placed upon 
the forehead, and is secured by two circular turns passing around the 
head from the forehead to the occiput. From the occiput the band- 
age is carried obliquely over the highest part of the lateral aspect 
ot the head, which is to be covered in, and is passed over the fore- 
head and back to the occiput, and is then carried to the forehead 
by a circular turn, then conducted obliquely over the other side of the 
head, and back to the occiput. These turns are repeated, so that 
each succeeding turn covers in three-fourths of the preceding turn 
until the sides of the head are covered in by descending turns, a 
circular turn being made between each set of oblique turns, and the 
bandage IS comp eted by a circular turn passing around the head from 
the forehead to the occiput (Fig. 34). This bandage may be applied 
with descending or ascending turns. 

Use.— This bandage is employed to make pressure upon or to hold 
dressings to the lateral aspects of the head. 



BANDAGES. 



37 



Fig. 35. 



Ocoipito-frontal Bandage. — BoUer two inches in width, four yards 
in length. — Application. — The initial 
extremity of the bandage is placed upon 
the forehead, and a circular turn is made 
around the forehead and occiput to fix 
it. A circular turn is then made, passing 
around the head from a point below the 
occiput to a point just above the fore- 
head; the next circular turn is made 
around the head, ascending posteriorly 
and descending anteriorly, and after a 
sufficient number of turns have been 
made to cover in the front and back of 
the head, the end of the bandage is 
secured with a pin (Fig. 35). 

Use. — This bandage will be found 
useful in securing dressings to the fore- 
head and anterior and posterior portion 
of the scalp. 




Occiplto-frontal bandage. 



Bandages of the Upper Extremity. 



Fig. 36. 



Spiral Bandage of the Finger. — Roller one inch in width, one and 
a half yards in length. — Application. 
— The initial extremity of the roller 
is secured by two or three turns around 
the wrist ; the bandage is then carried 
obliquely across the back of the hand 
to the base of the finger to be covered 
in, then to. its tip by oblique turns ; 
a circular turn is then made, and the 
finger is covered by ascending spiral 
or spiral reversed turns until its base 
is reached ; the bandage is then carried 
obliquely across the back of the hand 
and finished by one or two circular 
turns around the wrist ; the extremity 
may be pinned or may be split into 
two tails, which are tied around the 
wrist (Fig. 36). 

Use. — This bandage is employed 
to retain dressings upon the finger 
and to secure splints in the treatment 
of fractures or dislocations of the phalanges. 

Gauntlet Bandage. — Roller one inch in width, three yards in length. 
— Application. — The initial extremity of the roller is fixed at the 
wrist by one or two circular turns of the bandage ; it is then carried 
down to the tip of the thumb by an oblique turn of the roller, and this 
is covered in by spiral or spiral reversed turns to the metacarpo-phalangeal 
articulations ; the roller is then carried back to the wrist and a circular 
turn is made around it, and the bandage is now carried down to the tip 




Spiral bandage of the finger. 



38 



MINOR SUROERl. 



of the next finger by an oblique turn, which is covered in in the same 
manner. When all the fingers have been covered in, the bandage is 
finished by circular turns around the hand and wrist (Fig. 37). 

Use.— This bandage may be employed to apply dressings to the 
fingers and hand in cases of wounds or fractures. It was formerly 
much employed in the treatment of burns of the fingers to prevent the 
opposed ulcerated surfaces from adhering, but its use for this purpose 
has been supplanted by wrapping each finger in a separate dressing and 
applying a dressing over the whole with a few recurrent and spiral turns 
of a wide roller, the application of this dressing being much less painful 
to the patient, and being at the same time equally satisfactory. 



Fig. 37. 



Fig. 38. 





Gauntlet bandage. 



Spica bandage of the thumb. 



Spica Bandage of the Thumb. — Holler one inch in width, three 
yards in length. — Application. — The initial extremity of the roller is 
placed upon the wrist and fixed by two circular turns ; then carry the 
roller obliquely over the dorsal surface of the thumb to its distal 
extremity ; next make a circular or spiral turn around the thumb, and 
carry the bandage upward over the back of the thumb to the wrist, 
around which a circular turn should be made. The roller is next 
carried around the thumb and wrist, making figure-of-8 turns, each 
turn overlapping the previous one two-thirds as it ascends the thumb, 
and each figure-of-8 turn alternating with a circular turn about the 
wrist. These turns are repeated until the thumb is completely cov- 
ered in with spica turns, and the bandage is finished by a circular turn 
around the wrist (Fig. 38). 

Use. — This bandage is employed to apply dressings to the dorsal 
surface of the thumb and for the retention of splints in the dressing 
of fractures or dislocations of the bones of the thumb. 

Spiral Reversed Bandage of the Upper Extremity. — Roller two 
and a half inches in width, seven yards in length. — Application. — The 
initial extremity of the roller is placed upon the wrist and secured by 



BANDAGES. 



39 



two turns around the wrist ; the bandage is then carried obliquely across 
the back of the hand to the second joint of the iingers, where a circular 
turn should be made ; the hand is covered in by two or three ascending 
spiral or spiral reversed turns. When the thumb has been reached its 
base and the wrist are covered in by two iigure-of-8 turns ; the bandage 
is then carried up the forearm by spiral and spiral reversed turns until 
the elbow is reached ; this may be covered in with spiral reversed turns, 
and the bandage is next carried up the arm with spiral reversed turns to 
the axilla (Fig. -39). If on reaching the elbow the arm is bent or is to 

Fig. 39. 




Spiral reversed bandage of the upper extremity. 



be flexed in the subsequent dressing, the elbow should be covered in 
with figure-of-8 turns, and when this has been done the arm may be 
covered in with spiral reversed turns. When properly applied the 
reverses should be in line, and should not be made over the prominent 
ridge of the ulna. 

Use. — This is one of the most generally employed of all the roller 
bandages ; it constitutes the primary roller which is applied in the dress- 
ing of fractures of the humerus, and is also the bandage employed in 
holding dressings to the arm and forearm, and in securing splints to these 
parts in the treatment of fractures and dislocations. 

Figure-of-8 Bandage of the Elbow. — Roller two inches in width, 
four yards in length. — Application. — The initial extremity of the 
bandage is placed upon the forearm a short distance below the elbow- 
joint, and fixed by one or two circular turns, the arm being flexed. The 
bandage is then carried by an oblique turn across the flexure of the 
elbow-joint, and passed around the arm a few inches above the elbow ; 
a circular turn is then made, and the roller is next carried across the 
flexure of the elbow and passed around the forearm. These turns are 
repeated, and turns from the forearm ascending and those from the arm 
descending, each set of turns crossing in the flexure of the elbow until 
it is covered in, and a final turn is passed circularly around the elbow- 
joint (Fig. 40). This bandage is sometimes applied by first making 
one or two circular turns around the elbow and then applying the figure- 
of-8 turns as previously described. 

Use. — This bandage is often employed as a part, of the spiral reversed 
bandage of the upper extremity when the arm is to be flexed, and is also 
used to hold dressings to the region of the elbow-joint. It was formerly 



40 



MINOR SURGERY. 



much used to hold the compress upon the wound resulting from vene- 
section at the elbow. 

Fig. 40. 




Kgure-of-8 bandage of the elbow. 

Spica Bandage of the Shoulder (ascending). — Roller two and a 
half inches in width, seven yards in length. — Application. — The initial 
extremity of the roller is placed obliquely upon the outer surface of the 
arm opposite the axillary fold, and fixed by one or two circular turns. 
If the right shoulder is to be covered, the bandage is next carried across 

the front of the chest to the axilla 
Fig- 41. of the opposite side, then around the 

back of the chest to the point of 
starting upon the arm ; then conduct 
the roller around the arm of this 
side up over the shoulder, across 
the front of the chest, through the 
opposite axilla and back over the 
posterior surface of the chest to the 
point of starting ; continue to make 
these ascending turns, each turn 
overlapping the preceding one about 
two-thirds until the shoulder is cov- 
ered in (Fig. 41), when the extrem- 
ity of the bandage may be secured 
by a pin at the point of ending, or 
the last turn may be carried from 
the shoulder around the back of the 
neck and brought forward over the 
opposite shoulder and pinned to the turns which pass around the axilla. 
It should be remembered that the turns of the roller overlap each other 
exactly in the opposite axilla, and it will be found more comfortable to 
the patient to apply a little cotton wadding in the axilla to prevent the 
bandage from excoriating the skin of this part. Care should be taken 
to see that the turns are made in such a manner that the spica turns 
occupy, as nearly as possible, the median line of the shoulder. When 




Spica bandage of shoulder (ascendinj 



BANDAGES. 41 

this bandage is applied to the left shoulder, after fixing the initial 
extremity by circular turns around the arm the roller should be carried 
over the back of the chest to the axilla of the opposite side, and then 
brought back to the point of starting ; the succeeding turns are then 
applied in the same manner. 

Spioa Bandage of the Shoulder (descending). — Roller two and a 
half inches in width, seven yards in length. — Application. — The initial 
extremity of the roller should be fixed upon the arm as near as possible to 
the axillary fold by one or two circular turns, and if applied to the right 
shoulder the bandage should be passed under the axilla and carried 
obliquely over the shoulder to the 
base of the ueck, then downward 
across the front of the chest to the 
axilla of the opposite side ; from the 
axilla the roller is carried over the 
back of the chest to the base of the 
neck, so as to cross the first turn at 
this point ; it is then carried to the 
axilla and through this, then back 
to the neck, the turns descending 
toward the shoulder. These turns, 
taking the same course, are repeated, 
each turn overlapping two-thirds of 
the previous one until the shoulder 
is covered in and the circular turn 
around the arm is reached, at which 
point the extremity is secured by a 

'■ /"p:„ Ai)\ Spiea bandage of shoulder (descending). 

Use. — The spica bandages of the shoulder are employed to hold 
dressings to the shoulder, to hold compresses over the acromial end of 
the clavicle in case of dislocation of that portion of the bone, to retain 
the shoulder-cap used in the treatment of fractures of the upper portion 
of the humerus, and to retain dressings to the axilla. 

Velpeau's Bandage. — Tivo roUers tv)0 and a half inches in width, 
seven yards in length. — Application. — The patient should place the 
fingers of the hand of the aifected side on the opposite shoulder ; the 
initial end of the roller should be placed on the body of the scapula of 
the sound side and secured by a turn made by carrying the bandage over 
the shoulder of the aifected side, near its outer portion, then conducting 
it downward over the outer and posterior surface of the arm of the same 
side, behind the point of the elbow, and obliquely across the front of the 
chest to the axilla of the opposite side, thence to the point of starting. 
This turn should be repeated, to fix the initial extremity of the bandage. 
Having completed the second turn, carry the roller transversely around 
the thorax, passing over the flexed elbow of the affected side, from this 
point to the axilla, and through this to the back. From this point the 
roller is carried over the shoulder and down the outer and posterior sur- 
face of the arm behind the elbow, and obliquely across the front of the 
chest through the axilla to the back, and, continuing, passes transversely 
across the back of the chest to the elbow, which it encircles, then 
passes to the axilla. These alternating turns are repeated until the arm 




42 



MINOR SURGERY. 




Velpeau's bandage. 



and forearm are bound firmly to the side and chest. The vertical turns 
over the shoulder, each turn covering in two-thirds of the previous turn, 

and ascending from the point of the 
Fig- 43. shoulder toward the neck and from 

the posterior surface of the arm to- 
ward the elbow, are applied until the 
point of the elbow is reached. The 
transverse turns passing around the 
chest and arm are so applied that they 
ascend from the point of the elbow 
toward the shoulder, each turn cover- 
ing in one-third of the previous one, 
and the last turn should pass trans- 
versely around the shoulder and chest, 
covering the wrist (Fig. 43). 

The extremity of the bandage 
should be secured by a pin where it 
ends, and additional fixation will be 
secured by introducing a number of 
pins at the points where the turns 
of the bandage cross each other. 

Use. — This bandage is employed to fix the arm in the treatment of 
certain fractures of the clavicle and scapula ; also to secure fixation of the 
humerus after the reduction of dislocations of the shoulder-joint. 

Desault's Bandage. — Three rollers two and a half inches in width, 

seven yards in length. — A wedge-shaped pad to fit in the axilla is also 

required. These rollers are known as the first, second, and third rollers. 

First roller of Desault's bandage. — Application. — Before applying 

the first roller the arm of the patient 
on the injured side should be elevated 
and carried o& at right angles to the 
body ; the wedge-shaped pad with its 
base in the axilla should next be applied 
to the side of the chest, and the initial 
extremity of the roller is placed upon 
the middle of the pad and fixed by two 
or three circular turns around the chest ; 
the bandage is then carried down the 
chest by oblique circular turns until the 
lower extremity of the pad is reached, 
and it is then carried up the chest until 
the upper extremity of the pad is 
reached, when it is conducted obliquely 
across the front of the chest to the 
sound shoulder and passed under the axilla, brought over the shoulder 
and conducted around the chest, where it is secured (Fig. 44). 

Second roller of Desault's bandage. — Application. — The arm should 
be brought down against the side, so as to press upon the pad previously 
applied, and the forearm should be flexed upon the arm and brought 
across the lower portion of the chest. The initial extremity of the roller 
is placed in the axilla of the sound side, and the bandage is carried 



Fig. 44. 




First roller of Desault's bandage. 



BANDAGES. 



43 



around the chest and over the arm of the injured side, making a circular 
turn around the chest to fix it ; then spiral turns are made around the 
chest from above downward until the elbow is reached, the turns being 
more firmly applied as they descend, and when this point is reached the 
end of the bandage is secured. Or the initial extremity of the bandage 
may be placed upon the chest of the sound side, and a circular turn may 
be made to fix it, and then spiral turns including the chest and arm may 
be made from below upward until the axilla is reached (Fig. 45). 



Fig. 45. 



Fig. 46. 




Second roller of Desault's bandage. 



Third roller of Desault's bandage. 



Third roller of DesauWs bandage. — AppLiCATiON.^The initial ex- 
tremity of the roller is placed in the axilla of the sound side, and the 
bandage is carried obliquely over the front of the chest to the shoulder 
of the injured side, passed over this, and conducted down the back of 
the arm to the elbow, thence obliquely upward over the upper fifth of 
the forearm to the axilla of the sound side. From this point it is carried 
backward obliquely over the back of the cheat to the shoulder ; crossing 
the previous shoulder-turn, it is conducted down the front of the arm 
to the elbow, then around this and backward obliquely over the back of 
the chest to the axilla of the sound side. These turns are repeated until 
three sets of turns have been applied, which should overlie each other 
exactly (Fig. 46). The course of the turns of the third roller is con- 
sidered the most difficult to remember, and the student may be assisted 
in its correct application by remembering that all the turns start at the 
axilla, pass to the shoulder, and then to the elbow, and from the elbow 
always return to the starting-point, the axilla. The turns of the third 
roller make two triangles, one on the anterior surface of the chest, the 
other upon the back. 

After the application of the three rollers the hand and uncovered 
portion of the forearm should be supported in a sling suspended from 
the neck. 

Use. — This bandage, applied completely, or some one of its various 
rollers, is employed in the treatment of fractures of the clavicle. 

Arm-and-chest Bandage. — Roller tv)0 and a half inches in undth, 
seven yards in length. — Before applying this bandage the arm should be 
placed against the side of the chest and a folded towel or a pad of cotton 
should be placed in the axilla and allowed to extend from the axilla ta 



44 



MINOR SURGERY. 



the elbow ; the latter is used to prevent the opposing surfe«es of skin 
from becomiag excoriated by contact. 

Application. — The initial extremity of the bandage is placed upon 
the spine at a point opposite the elbow-joint, and it is fixed by a turn or 
two passing around the arm and chest ; the bandage is then continued 
by making ascending spiral turns, covering in the arm and chest, until 
the axilla is reached ; at this point the bandage is carried through the 
axilla and over the back of the chest to the top of the opposite shoulder, 
and it is then conducted down the front of the arm to the elbow, is 
passed between the arm and chest and carried up the back of the arm to 
the shoulder, and is then passed obliquely across the front of the chest 
and is secured upon the back of the chest. Pins should be introduced 
at the points of crossing of the bandage (Fig. 47). 

Fig. 47. 




Ann-and-chest bandage. 

Use. — This bandage will be found useful in fixing the arm to the 
body and in fixing the shoulder-joint where it is desirable to allow the 
forearm to be free. It is employed in the treatment of fractures of the 
shaft and neck of the humerus, to fix the arm and hold splints in posi- 
tion. 

Bandages op the Trunk. 

Spiral Bandage of the Gla&st.— Roller three inches in width, nine 
yards in length. — Application. — The initial extremity of the roller is 
applied to the anterior portion of the waist, and fixed by one or two cir- 
cular turns ; the bandage is then carried upward, encircling the chest 
by ascending spiral turns, each turn covering in one-half of the previous 



BANDAGES. 



45 



Fig. 48. 



turn until the axillary fold is reached ; the roller is next carried around 
the axilla to the back, and obliquely over this to the base of the neck of 
the opposite side, and then it may be passed 
down over the chest and pinned to the 
spiral turns at several points ; a pin should 
also be inserted at the point where the last 
turn of the roller leaves the spiral turn upon 
the back of the chest (Fig. 48). 

Use. — This bandage is employed to hold 
dressings to the chest, and may be used as a 
temporary dressing in fractures of the ribs 
or sternum. Care should be taken that 
the bandage be not so tightly applied as to 
interfere with respiration. 

Anterior Figure-of-8 Bandage of the 
Chest. — Roller two and a half inches in 
width, seven yards in length. — Applica- 
tion. — The initial extremity of the roller 
should be placed in the axilla of one side, 
and the bandage is then carried obliquely across the anterior portion of the 
chest to the shoulder of the opposite side ; it is then carried backward 
around the shoulder and through the axilla, and is next conducted ob- 
liquely over the anterior portion of the chest to the opposite shoulder, 
through the axilla and again back to the anterior portion of the chest, 
the turns crossing in the median line over the sternum. These turns 
should be repeated, ascending from the shoulder toward the neck, each 
turn overlapping three-fourths of the preceding one, until five or six 
turns have been applied, the end of the bandage being secured by a pin 
(Fig. 49), or it may be completed by a circular turn around the chest. 




Spiral bandage of the chest. 



Fig. 49. 




Anterior flgure-of-8 bandage of the chest. 



Use. — This bandage may be employed to bring the shoulders forward 
and to hold dressings to the anterior portion of the chest. 

Posterior Pigure-of-8 Bandage of the Chest. — Boiler tivo and a 
half inches in width, seven yards in length. — Application. — The initial 
extremity of the roller should be placed in the axilla of the left side, 
and the bandage is then carried obliquely across the back of the chest to 
the tip of the opposite shoulder ; it is next carried through the axilla and 



46 



MINOR SURGERY. 



conducted across the posterior portion of the chest to the tip of the oppo- 
site shoulder, and passed through the axilla to the point of starting. 
These turns are repeated, ascending from the shoulder toward the neck, 
until five or six have been applied, the end of the bandage being secured 



Fig. 50. 




Posterior figure-of-8 bandage of the chest. 

by a pin (Fig. 60). In applying both of these bandages the crosses of 
the bandage, either anterior or posterior, should be made in the median 
line of the chest. 

Use. — This bandage may be employed to hold dressings to the pos- 
terior portion of the chest and to draw the shoulders backward. 

Suspensory and Compressor Bandage of the Breast. — Roller two 

and a half inches in width, seven yards in 
Fig. 51. length. — APPLICATION. — The initial ex- 

tremity of the roller should be placed 
upon the scapula of the affected side, and 
secured by two oblique turns carried over 
the opposite shoulder and conducted down- 
ward under the breast to be covered in, 
and then carried to the axilla of the same 
side. Next carry the roller transversely 
around the chest, covering in the lowest 
portion of the affected breast. These turns 
should be repeated, the oblique turns from 
the axilla over the shoulder alternating 
with the transverse turns around the 
chest until the breast is covered in, each 
series of turns ascending and covering 
two-thirds of the preceding turn (Fig. 51). 
Use. — This bandage is employed to support the breast and to make 
compression at the same time ; it may also be employed to hold dressings 
to the breast. 

Suspensory and Compressor Bandage of Both Breasts. — Ikvo 
rollers two and a half inches in width, seven yards in length. — Applica- 
tion. — The initial extremity of the bandage should be secured by 
oblique turns of the axilla and shoulder as in the preceding bandage ; 
the roller should next be carried transversely around the back to the 
breast, then under the breast and upward over the opposite shoulder, 




Suspensory and compressor bandage 
of the breast. 



BANDAGES. 47 

then obliquely downward around the chest to the other side, being carried 
transversely over the lower portion of both breasts to the point of 
starting upon the back. Repeat these oblique turns from the shoulder 
to the breast and from the breast to the shoulder, and alternate them 

FiGf. 52. 




Suspensory and compressor bandage of both breasts. 

with a transverse turn around the chest and over both breasts. Both 
series of turns should ascend, and each turn should overlap two-thirds 
of the preceding one (Fig. 52). 

Use. — This bandage is employed to support and compress both 
breasts and to retain dressings to them. 

Bandages of the Lower Exteemity. 

Single Spioa Bandage of the Groin (ascending). — Roller two and 
a half inches in width, seven yards in length. — Application. — Place 
the initial extremity of the bandage upon the anterior portion of the 
right thigh just below the groin, and secure it by one or two circular 
turns around the thigh, or place the initial extremity of the roller 
obliquely upon the upper part of the thigh, and carry it behind the 
limb and upward around the outer side of the thigh to the abdomen, 
omitting the circular turns ; then carry the bandage obliquely across the 
lower part of the abdomen to a point just below the crest of the left 
ilium, and conduct it transversely around the back of the pelvis to 
a corresponding point on the opposite side ; then bring it obliquely 
downward to the groin over to the inner portion of the thigh, carrying 



48 MINOB SUBGEMY. 

it around the limb, crossing the starting-turn in the middle line of the 
thigh. These turns are repeated, each turn ascending and covering in 
two-thirds of the previous turn, until six or eight complete turns have 
been made, and the bandage is secured at any point where it ends 
(Fig. 53). 

Fig. 53. Fw- 54. 




Ascending spica bandage of the groin. Descending spica bandage of the groin. 

Single Spica Bandage of the Groin (descending). — Boiler two 
and a half inches in width, seven yards in length. — Application. — 
Place the initial extremity of .the roller obliquely upon the anterior 
surface of the right thigh, and secure it by one or two circular turns- 
around the limb, or start the bandage with an oblique turn, as previously 
described ; then carry the bandage obliquely across the abdomen to 
a point just below the crest of the ilium, and conduct it transversely 
around the back of the pelvis to a corresponding point on the opposite 
side ; then bring it obliquely down over the lower portion of the abdo- 
men, crossing the first turn, to the junction of the thigh with the 
scrotum ; pass it under the thigh and bring it up over the lower part 
of the abdomen, and let it follow the course of the first turn. These 
turns are repeated, each turn descending and overlapping two-thirds of 
the previous turn until the groin is covered (Fig. 54). When either 
of these bandages is applied to the left groin, after the initial extremity 
of the roller is fixed it is carried first to the crest of the ilium of the 
same side, then around the back of the pelvis to a corresponding point 
on the opposite side, then obliquely across the lower part of the abdomen 
to the outer aspect of the thigh, being conveyed under this and brought 
up between the thigh and the scrotum, passing obliquely over the groin 
to follow the course of the original turn. 

Use. — The spica bandages of the groin are employed to hold dress- 
ings to wounds in the inguinal region ; for instance, to those resulting 
from herniotomy or from operation upon the glands of the groin. They 
are also employed to make pressure upon this region, and will often prove 
of use in the securing of compre.sses applied for the temporary retention 
of hernise. 



BANDAGES. 



49 



Fig. 55. 



Spica Bandage of Buttock. — Roller two and a half inches in width, 
seven yards in length. — Application. — The initial extremity of the 
bandage is placed upon the back of 
the thigh just below the gluteal fold, 
and is carried around the thigh and 
brought back to the posterior aspect 
of the limb, so as to fix and cross the 
starting turn near the middle of the 
thigh. It is next conducted ob- 
liquely across the thigh and but- 
tocks and carried to the brim of 
the pelvis of the opposite side, when 
it is brought obliquely over the ab- 
domen and back to the posterior 
surface of the thigh. There ascend- 
ing turns are applied, each turn cov- 
ering in about three-fourths of the 
preceding one, until the buttock is 
covered, and the bandage is then 
finished by one or two circular 
turns around the pelvis and abdo- 
men (Fig. 55). 

Use. — This bandage is employed 
to hold dressings to the upper posterior portion of the thigh or the 
buttock. 

Pigure-of-8 Bandage of the Knee. — Roller two and a half inches 
in width, five yards in length. — Application. — The initial extremity of 
the roller is placed upon the thigh three inches above the patella, and 
secured by two or three circular turns ; then conduct the bandage over 
the outer condyle of the femur across the popliteal space to the inner 
border of the tibia, and around the anterior surface below the tubercle 
and head of the fibula, and make one circular turn ; the roller should 




Splca bandage of buttock. 



FiQ. 56. 



Fig. 57. 





Figure-of-8 bandage of the knee. 



Figure-of-S bandage of both knees. 



then be carried obliquely across the popliteal space to the inner condyle 
of the femur, crossing the previous turn ; then carry it around the front 
of the thigh to the outer condyle ; repeat these turns, ascending toward 
the knee from the leg, and descending from the thigh toward the 

Vol. II.— 4 



50 MINOR SUBQEBY. 

knee, and finish tlie bandage by a circular turn over the patella 

(Fig. 56). 

Use. — This bandage is employed to hold dressings to the knee-jomt 
either anteriorly or posteriorly. These figure-of-8 turns are often em- 
ployed in covering the knee in applying the spiral reversed bandage of 
the lower extremity when it is desired that the patient be allowed to 
bend the knee. 

Pigure-of-8 Bandage of Both Knees. — Roller two and a half 
inches in width, seven yards in length. — Application. — Place the knees 
of the patient together with a compress between them ; then place the 
initial extremity of the roller upon one thigh about three inches above 
the patella, and secure it by one or two circular turns around both 
thighs ; then conduct the roller from the outer condyle of the femur 
obliquely across the popliteal spaces of both legs to the head of the 
fibula on the opposite side, making a circular turn around both legs ; 
pass the roller from the head of the fibula on the opposite side across 
the popliteal space to the external condyle opposite the point of start- 
ing. Repeat these turns, descending from the thighs and ascending 
from the legs, until the knees are covered, and finish the bandage by 
carrying a turn of the bandage at right angles to the previous turns 
between the thighs and the legs (Fig. 57). 

Use. — This bandage is employed to secure fixation of the limbs after 
operation upon the perineum, and may also be employed to obtain tem- 
porary fixation of the limbs in transporting cases of fracture of the neck 
of the femur and after the reduction of dislocations of the head of the 
femur. 

Spica Bandage of the Foot. — Roller two and a half inches in width, 
five yards in length. — Application. — Fix the initial extremity of the 
roller upon the ankle and secure it by two circular turns ; then carry the 
bandage obliquely over the dorsum of the foot to the metatarso-phalangeal 
articulation, and make a circular turn around the foot at this point ; then 
continue it upward over the metatarsus by making two or three spiral 
reversed turns ; next carry the bandage parallel with the inner or outer 
margin of the sole of the foot, according to whether it is applied to the 
right or left foot, directly across the posterior surface of the heel ; thence 

along the opposite border of the foot 
J^iP- 58. and over the dorsum, crossing the orig- 
inal turn in the median line of the foot. 
This completes the first spica turn. 
These spica turns are repeated, gradu- 
ally ascending by allowing each turn 
to cover in three-fourths of the pre- 
ceding turn, until the foot is covered 
in with the exception of the posterior 
portion of the sole of the heel (Fig. 
58). Care should be taken to see 
that the turns cross each other in the 
median line of the foot, and that they 
Spica bandage of the foot. are kept parallel to each other through- 

out their course. 
Use. — This bandage will be found very useful when it is desired to 




BANDAGES. 



61 



make firm compression upon tlie foot or to retain dressings to it ; it is 
especially useful in the treatment of sprains of the ankle or anterior 
tarsus. 

Bandage of Foot covering the Heel (American). — Roller two and 
a half inches in width, seven yards in length. — Application. — The ini- 
tial extremity of the roller is placed upon the leg just above the malleoli 
and fixed by two circular turns around the leg ; the bandage is then car- 
ried obliquely across the dorsum of the foot to the metatarso-phalangeal 
articulation, at which point a circular turn is made ; two or three spiral 
or spiral reversed turns are then made, ascending the foot ; the roller is 
next carried directly over the point of the heel and continued back to 
the dorsum of the foot ; thence beneath the instep around one side of 
the heel and up over the instep ; from this point it is carried beneath the 
instep around the other side of the heel and up in front of the ankle, 
from which point it may be continued up the leg (Fig. 59). 

Use. — This bandage is employed to cover in the foot and retain 
dressings to the foot and heel. 



Fig. 59. 



Fig. 60. 




Bandage of foot covering the heel. 



Bandage of foot not covering the heel. 



Bandage of Foot not covering the Heel (French). — Holler two and 
a half inches in width, seven yards in length. — Application. — Fix the 
initial extremity of the roller upon the leg just above the malleoli, and 
secure it by two circular turns around the leg ; the bandage is then car- 
ried obliquely across the dorsum of the foot to the metatarso-phalangeal 
articulation, and at this point a circular turn around the foot is made. 
The roller is now carried up the foot, covering it in with two or three 
spiral reversed turns, and at this point a figure-of-8 turn is made around 
the ankle and instep ; this should be repeated once, which will cover in 
the foot with the exception of the heel ; the bandage may then be con- 
tinued up the leg with spiral reversed turns (Fig. 60). 

Use. — This bandage may be employed to secure dressings to the foot, 
and is the one generally used to cover the foot in applying the spiral 
reversed bandage of the lower extremity. 

Spiral Reversed Bandage of the Lower Extremity. — Holler two 
and a half inches in width, seven yards in length. — Application. — The 
initial extremity of the roller is placed upon the leg just above the mal- 
leoli and secured by two circular turns, then carried obliquely over the 



52 MINOR SURGERY. 

foot to the metatarso-phalangeal articulation ; and here a circular turn is 
made around the foot ; the foot is next covered in with two or three 
spiral reversed turns and two figure-of-8 turns of the ankle and instep, 
and just above the ankle one or two circular or spiral turns are made 
around the leg, and as the bandage is carried up the leg, as it increases 
in diameter, spiral reversed turns are made until it approaches the knee ; 




Spiral reversed bandage of the lower extremity. 

at this point, if the limb is to be kept straight, the spiral reversed turns 
may be continued over this region and up upon the thigh. If the knee 
is to be bent, figure-of-8 turns may be applied until the knee is covered, 
and then the thigh may be covered with spiral reversed turns (Fig. 61). 
To cover in the thigh as well as the leg two bandages of the dimensions 
before given will be required. Care should be taken to keep the reverses 
in a line, and not to make them over the spine of the tibia, as they may 
thus become painful to the patient. 

Use. — This is one of the most frequently employed of the roller 
bandages ; it is used to apply pressure to the lower extremity, to retain 
dressings, and to secure splints in the treatment of fractures and dislo- 
cations. 

Fig. 62. 




Figure-of-8 bandage of tbe leg. 



Pigure-of-8 Bandage of the l^eg.— Roller two and a half inches 
m width, seven yards in length. — Application.— This bandage differs 



BANDAGES. 



53 



from the spiral reversed bandage of the lower extremity only in the fact 
that when the swell of the calf is reached figure-of-8 turns are made 
around the leg instead of spiral reversed turns. In applying the roller, 
when the calf of the leg is reached the bandage is carried obliquely 
around the leg and brought in front of the leg, and made to cross the 
starting turn in the median line ; these turns are repeated until the calf 
of the leg has been covered in, and the bandage is finished with one or 
two circular turns just below the knee (Fig. 62). 

Use. — This bandage holds its place more hrmly than the ordinary 
spiral reversed bandage of the leg, and may be employed in the treat- 
ment of ulcers of the leg, in conjunction with strapping, where it is de- 
sirable to change the dressings at infrequent intervals and to allow the 
patient to walk about during the course of treatment. 



Fig. 63. 



Special Bandages. 

Spiral Reversed. Bandage of the Penis. — Roller three quarters of 
an inch in width, thirty inches in length. — Application. — Fix the initial 
•extremity of the roller by two circular 
turns around the penis close to the pubis ; 
then carry the bandage obliquely down 
to the corona glandis ; from this point 
ascend the body of the penis by spiral 
reversed turns to the pubis and finish the 
bandage by two figure-of-8 turns around 
the neck of the scrotum and root of the 
penis ; split the end of the bandage so as 
to form two tails, and secure it by tying 
these around the root of the penis (Fig. 
63). 

Recurrent Bandage of Stump. — Roller 
two and a half inches in width, five to seven 
yards in length. — Application. — Place 
the initial extremity of the roller upon the 
anterior or posterior surface of the limb a 
few inches above the extremity of the 
stump, and carry the bandage to the end 
of the stump, and then conduct it upward or downward on the limb, as 
the case may be, to a point directly opposite the point of starting ; then 
bring the bandage back over the face of the stump to the point of start- 
ing, and continue these recurrent turns, each turn overlapping two-thirds 
of the previous one, until the face of the stump is covered ; then reverse 
the bandage and secure the recurrent turns at their points of origin by 
two or three circular turns. The roller should next be carried obliquely 
down to the end of the stump, and a circular turn should be made 
around this ; and the bandage should next be carried up the limb by 
spiral or spiral reversed turns beyond the point at which the recurrent 
turns terminated, and secured by one or two circular turns (Fig. 64). 

In applying this bandage in very short stumps resulting from ampu- 
tations at or near the shoulder- or hip-joint, after making the recurrent 
and spiral turns it will be found necessary to carry the bandage, in the 




Spirttl reversed bandage uf the penis. 



54 



MINOR SURGERY. 



case of the shoulder, across the chest to the opposite axilla and back, 
and apply several of these turns ; so in case of hip amputations it will be 
found best to finish the bandage with a fevf turns about the pelvis. 



Fig. 64. 




Recurrent bandage of stump. 

Bandage for Securing the Hands and Feet in the Lithotomy 
Position. — Roller two and a half inches in width, three yards in length. 
— Application. — The hand of the patient should be brought down and 
made to grasp the outer side of the foot ; the initial extremity of the 
roller is fixed by two circular turns around the wrist and ankle, and the 
bandage is then passed around the foot and hand, and these turns are 
alternated with turns around the wrist and ankle until the hand and 
foot are firmly secured. The same procedure is adopted with the hand 
and foot of the opposite side (Fig. 65). 

Use. — This bandage is useful in securing the hands and feet while 



Fig. Go. 



Fig. 6G. 





Bandage for securing hands and feet for lithotomy. Liebrelch's eye bandage. 

the patient is put in the lithotomy position for that operation or for 
perineal section. 



BANDAGES. 



55 



Liebreioh's Bye Bandage. — This bandage consists of a strip of 
flannel two and a half inches in width and from six to ten inches in 
length, to the extremities of which are sewed tapes. It may be applied 
transversely so as to cover both eyes, or obliquely so as to cover one eye 
only, and is secured by the tapes carried around the head and tied over 
the forehead (Fig. 66). 

Use. — This bandage is used to hold compresses or dressings to the 
eye or eyes, and the elasticity of the flannel permits of its being applied 
so as to make a variable amount of pressure. 

Bandage of Scultetus. — This is a compound bandage, consisting of 
a number of pieces of muslin, and may be prepared from a two-and-a- 
half or three-inch roller by cutting ofi" strips long enough to encircle the 
part about one and one-third times. 
These strips are placed under the part Fig. 67. 

in such a manner that the first piece 
shall be overlapped by the second, the 
second by the third, and so on from 
below upward ; the pieces are then 
brought around the limb and the ex- 
tremities of the last piece are secured 
by pins (Fig. 67). This bandage was 
formerly much employed in the treat- 
ment of compound fractures to secure 
dressings to the wound, and possessed 
the advantage that when a single strip 
became soiled it could be removed 
without disturbing the whole dressing, 
the new strip to be introduced being 
pinned to the extremity of the soiled 
piece to be removed, and then being 
drawn through by its removal. This 
bandage will often be found convenient 
in applying dressings to cases of ex- 
cision of the joints where as little dis- 
turbance of the parts as possible is im- 
portant in dressing the wounds. When 
the strips are attached to each other 
by a thread passed through each strip 
in the centre the bandage is known as Pott's bandage. This bandage is 
applied and secured in the same manner, but it possesses no advantages 
over the bandage of Scultetus. 

Flannel Bandage. — These bandages are prepared from flannel, which 
is cut into strips from two to four inches in width and from five to seven 
yards in length. Flannel bandages, by reason of the elasticity which they 
possess, can be applied without reverses, and are used to make a mod- 
erate amount of elastic pressure. They are often employed in applying 
dressings to the head, especially after operations upon the eyes, and are 
generally applied as a primary roller before the application of the 
plaster-of-Paris dressing, and may also be used in subacute joint affec- 
tions, both to protect the parts and make a moderate amount of elastic 
pressure. 




Bandage of Scultetus. 



56 MINOR SUJROEBY. 

The Rubber Bandage. — This bandage is made from a strip of rubber 
sheeting from one inch to four Laches in width and from three to five 
yards in length, which, for convenience of application, is rolled into a 
cylinder. Its use was introduced to the profession by Dr. Martin of 
Boston, and it will be found a useful form of dressing where it is consid- 
ered desirable to apply elastic pressure to a part. It may be employed 
in the treatment of varicose veins of the legs, in chronic ulcers of those 
parts where pressure is an important element in the treatment, and may 
be used as a substitute for strapping to secure this object. Its applica- 
tion has also been recommended in the treatment of swelled testicle in 
that stage of the affection in which pressure is indicated. 

Application. — For application to the leg a rubber bandage two and 
a half inches in width and three yards in length is required. The initial 
extremity of the roller is fixed upon the foot near the toes and secured 
by a circular turn ; the foot is then covered in by spiral turns overlapping 
each other about two-thirds, and a figure-of-8 turn is made from the ankle 
to the instep, and the bandage is then canned up the limb to the knee 
with spiral turns, where it is secured by two tapes sewed to the terminal 
extremity of the bandage, which are passed around the leg and tied. The 
bandage need not be reversed, as its elasticity allows it to conform to the 
shape of the limb. Care should be taken not to apply the turns with too 
much firmness ; the bandage should be stretched very slightly ; if this 
precaution is not taken, it soon becomes uncomfortable to the patient. A 
patient using one of these bandages will soon learn to apply it himself, 
making just the requisite amount of tension to secure its holding its 
place and to ensure a comfortable amount of pressure upon the part. A 
well-fitting stocking may be placed upon the limb before the bandage 
is applied or it may be applied directly to the skin. 

The bandage should be removed at night when the patient goes to 
bed and hung up to dry, as its inner surface becomes moist from the 
secretions from the skin ; it should be reapplied as soon as the patient 
rises in the morning. 

In using it in the treatment of ulcers of the leg no ointments should 
be applied to the ulcer, as oily dressings soon destroy the rubber ; dress- 
ings may be made to the ulcer by means of dry powders, such as oxide 
of zinc, iodoform, or aristol, before the bandage is applied. 

In the treatment of swelled testicle the bandage is applied to the tes- 
ticle by means of recurrent turns not too firmly made, and secured in 
place by spiral turns until the whole surface of the organ is covered in ; 
the end of the bandage is secured with tapes tied around the root of the 
scrotum. The same precaution to apply the bandage so as to make only 
moderate pressure should here also be observed. 

Fixed Dressings or Hardening Bandages. 

Fixed dressings are prepared from a variety of substances which are 
incorporated in the meshes of some fabric, such as crinoline or cheese- 
cloth, or painted over its surface to give fixity or solidity to the bandage. 
The materials most commonly used in the preparation of fixed dressings 
are plaster of Paris, starch, silicate of sodium or potassium, paraffin, or a 
mixture of chalk and gum or of oxide of zinc and glue. 



HARDENING BANDAGES. 57 

Plaster-of-Paris Bandage. — The plaster of Paris used for the prep- 
aration of surgical dressings should be of the same quality as that which 
the dental surgeons employ in taking casts for teeth ; that is, the extra- 
calcined variety. If moist or of inferior quality, it will not set rapidly 
or firmly and will fail to give sufficient fixation to the dressing. The 
plaster-of-Paris dressing may be applied in several ways, either by cover- 
ing the part to be enclosed with some loose fabric and rubbing the plas- 
ter of Paris into it, alternating the layers of the fabric with layers of 
moist plaster, or it may be applied by means of a roller which has been 
prepared with plaster of Paris and is moistened and applied to the part. 

In applying a plaster-of-Paris dressing according to the first method 
the part to be enclosed — the leg, for instance — should be covered by a 
neatly-applied flannel bandage or muslin bandage which has been 
shrunken by being washed ; new muslin is not satisfactory as a primary 
application to a limb in applying a plaster-of-Paris dressing, as the 
moisture from the plaster wets it and causes it to shrink, so that it may 
cause injurious pressure after the bandage becomes dry. The limb hav- 
ing been covered by the flannel bandage, and any bony prominences, 
such as the malleoli, having been padded with small wads of cotton to 
prevent undue pressure upon them, the parts are then covered by a layer of 
crinoline bandage or by strips of cheese-cloth or any other loose material. 
A small quantity of plaster of Paris is next mixed with water until it 
has the consistence of thick cream, when it is smeared evenly over the 
whole surface of the previously applied bandage. Another layer of the 
bandage or of strips is next applied until a casing of the desired thick- 
ness is obtained. If the plaster of Paris of the quality previously 
described be used, it will set or become hard in a few minutes. 

The most convenient method of applying a plaster-of-Paris dressing 
is that employed by Professor Sayre, which consists in the use of band- 
ages which have been previously prepared with plaster of Paris ; these 
are moistened and applied while moist to the parts to be encased. 

Preparation of Plaster-of-Paris Bandages. — These bandages are pre- 
pared by taking cheese-cloth, mosquito-netting, or crinoline — which lat- 
ter is by far the best fabric — and tearing or cutting it into strips two and 
a half to three inches in width and five yards in length. These are laid 
upon a table and plaster of Paris is dusted over them and rubbed into 
the meshes of the fabric, and when the material has been thoroughly 
impregnated with plaster it is loosely rolled into a cylinder ; the 
bandages when prepared should be placed in air-tight cans until required 
for use. 

Plaster-of-Paris bandages which have been exposed to the air or have 
been kept for a long time are not apt to set well when applied ; but if 
such bandages are placed in a hot oven and baked for a half hour before 
being used, they will set as satisfactorily as those freshly prepared. 

Plaster-of-Paris bandages may be prepared by a machine made for 
the purpose, but they are not apt to have the plaster as evenly dis- 
tributed through them, and therefore they are not as satisfactory as those 
prepared by hand. 

Application of the Plaster-of-Paris Bandage. — Before applying the 
plaster-of-Paris bandage the part to be encased — the leg, for instance — 
should be covered by a flannel roller, the bony prominences being pro- 



58 MINOR SURGERY. 

tected by pads of cotton, or a closely-fitting stocking may be applied to 
the part. The bandage, five yards in length, three inches in width, 
should be dipped in warm water and kept covered by water for a few 
minutes ; it may be squeezed with the hand, and as soon as the bubbles 
of air cease to escape it is a sign that it is thoroughly soaked and ready 
for application. On removing it from the water the excess of water 
should be squeezed out by the hand, and the bandage should be evenly 
applied to the part with just enough firmness to make it fit the part 
nicely, and as few reverses as possible should be made. A sufficient 
number of bandages are applied to make a dressing as firm as may be 
required ; three rollers of the above dimensions are usually quite ample 
for a dressing for the leg, and when the last roller has been applied, 
some dry plaster should be moistened with water until it has the con- 
sistence of thick cream, and it should then be rubbed evenly over the 
surface of the bandage to give it a finish (Fig. 68). If a good quality 

Fig. 68. 




Leg encased In plaster-of-Paris bandage. 



of plaster of Paris has been used, the bandage should be quite firm in 
from ten to fifteen mmutes, but the patient should not for a few hours be 
allowed to put any weight upon the bandage. 

An equally firm dressing may be applied with the use of a less num- 
ber ot bandages if the surgeon rubs over the surface of each layer of 
bandage applied a little moist plaster of Paris, then applies another layer 
ot bandage, and repeats the same procedure, finishing the dressing by" an 
external coat of moist plaster as above described. 

A fewer number of bandages will be required in applying these 
dressings if narrow strips of tin, zinc, or binder's board are incorporated 
in the layers of the bandage, and they also increase the strength of the 

Interrupted Plaster-of-Paris Dressing.— Thh form of plaster-of-Paris 
dressing IS applied by first placing a short iron rod or strip of iron under 
the part, extending some distance above and below the point at which 
the dressing ^ to be interrupted ; this is fixed by a few turns above and 
below the portion of the limb which is to be left exposed ; stout wire or 
strips of iron are next bent into loops, the extremities of which are incor- 
porated in the subsequent turns of the plaster bandage. Three Ioods 
thus secured, one on either side and one directly opposite the posterior 



HARDENING BANDAGES. 



59 



iron bar or strip, will usually make the dressing sufficiently firm (Fig. 
69). A number of turns of the bandage are applied to firmly fix the 



Fig. 69. 




Interrupted plaster-of-Paris dressing (Stimson). 



loops, and the limb is held in the desired position until the plaster of 
Paris has set. 

Application of Plaster-of-Paris Jacket. — The patient's body should 
be covered with a soft, closely-fitting woven seamless shirt without arms, 



Fig. 70. 



Fig. 71. 





Suspensory apparatus. 



Patient suspended for application of 
plaster-of-Paris jacket. 



but with shoulder-straps to hold it in position, or an ordinary woven 
undershirt may be employed ; one or two folded towels or a pad of cot- 
ton wrapped in a towel is next placed over the abdomen between the 



60 MINOR SUBGEBY. 

shirt and skin, called by Prof. Sayre the dinner-pad, and is intended to 
leave space for the distention of the abdomen after eating. Small pads 
of raw cotton may also be placed over the anterior iliac spines, and m 
the case of females a pad of cotton wrapped in a handkerchief may be 
placed over each mammary gland. The patient should next be sus- 
pended by the apparatus consisting of a collar and arm-pieces attached 
to a cross-bar (Fig. 70), which is attached by a cord and pulley to a 
tripod. If this apparatus is not at hand, a very satisfactory substitute 
may be made by folding two towels into cravats and tying together the 
ends so as to make two loops, one of which is placed in each axilla ; a 
bar of wood two and a half feet in length is next taken, and the loops 
are secured to the ends of this by stout cords or handkerchiefs ; a Barton's 
bandage is next applied to the head, and a strip of bandage is passed 
under, the turns which cross the vertex and secured to the middle of the 
cross-bar. The bar is next suspended by a cord passed through a pulley 
or ring which may be attached to the sill of a door if the ordinary tripod 
cannot be obtained. The patient should be raised by the apparatus until 
the toes only are in contact with the floor, and the extension should not 
be carried to the point which makes it uncomfortable to the patient 
(Fig. 71). 

Some surgeons omit making extension in applying plaster-of-Paris 
bandage, using only the head-gear for extension and omitting the exten- 
sion from the arm-piece. The shirt should be drawn downward from 
the hips by an assistant and held in place until a few turns of the band- 
age have been applied. The plaster bandage having been soaked and 
squeezed, a turn should be made around the body just above the pelvis ; 
it should then be carried downward, and several turns should be made 
around the body below the iliac spines, and from this point it should be 
made to ascend gradually by spiral turns until the axillary line is reached. 
The turns should be applied smoothly and not too tightly. After two or 
three layers of turns have been applied the surgeon may rub some moist 
plaster upon their surface if he desires to use fewer bandages. These 
turns are repeated until a bandage of the desired thickness is applied, 
and the surface of the dressing may be finished by rubbing it over with 
moistened plaster. The jacket for a child will usually require about 
three or four bandages of the dimensions given ; for an adult six or 
eight bandages will be required. 

The patient should be kept suspended until the bandage has set, 
usually from ten to fifteen minutes, and then should be carefully lifted, 
so as not to bend the spine, and placed on his back upon a mattress 
until the dressing becomes perfectly hard. The dinner-pad (and mam- 
mary pads, if the^ have been used) should next be removed. In 
applying this dressing strips of zinc or tin may be placed between the 
layers of bandage if it is desired to give more strength to the jacket. 
Great care must be exercised lest too much extension is applied and a 
serious accident occur. 

Application of Jury-mast by means of Plaster of Paris. — In disease 
of the spine involving the cervical and upper dorsal region an ordinary 
plaster-of-Paris jacket is not satisfactory, and in such cases the jury-mast 
is employed in connection with the plaster jacket. In applying the 
jury-mast the same steps are taken in the preparation of the patient 



HARDENING BANDAGES. 



61 



as in applying the plaster-of-Paris jacket, with the exception of exten- 
which need not be used. 



sion, 



Fig. 72. 



After the application of three or four layers of the plaster-of-Paris 
bandage to the body an apparatus made of 
two bars of metal having two perforated strips 
of zinc attached to them a few inches apart, 
which partly encircle the body, is applied and 
held in position by turns of the plaster band- 
age. The perpendicular bars have at their 
upper part a slot into which the lower end 
of the jury-mast fits and is secured by a 
screw ; to the upper part of this is attached a 
movable cross-bar, attached to which are fastened 
the straps of the collar from which the head is 
suspended (Fig. 72). 

The Bavarian Dressing. — In applying this 
dressing, which is sometimes employed in the 
treatment of fractures, take two pieces of canton 
flannel the length of the part to be enclosed and 
more than wide enough to envelop its circum- 
ference. In applying this dressing to the leg 
these pieces should be cut so as to correspond to 
the outline of the leg and posterior portion of the 
foot. These pieces should be placed one over the 
other, and sewed together in the middle line, the 
seam corresponding to the back of the leg. The leg and foot are then 
placed upon this, and the inner layer of flannel is brought up in front 
of the leg and over the dorsum of the foot and made fast with pins or 
strips (Fig. 73). Plaster of Paris is next mixed with water and made 




Head-support and jury-mast. 



Fig. 73. 




Bavarian dressing. 

into a paste, which is rubbed thickly over the flannel next to the surface 
of the limb until a sufficient thickness is obtained ; the outer layer of 
flannel is then brought up about the leg and moulded to its surface by 
the hands. A loosely -applied bandage may now be used to hold the 
dressing in place until the plaster has set. 

When it is necessary to inspect the parts the turns of the bandage 



62 MINOR SURGERY. 

are cut, and upon separating the layers of flannel the two halves can be 
turned aside, the seam at the back acting as a hinge. Upon reapplying 
the splints to the leg the dressing may be retained in position by a band- 
age or by one or two strips of muslin. 

Moulded Plaster Splints. — It is sometimes found dii5&cult to apply the 
ordinary plaster dressing to parts irregular in shape, and at the same 
time to have a splint which can be removed with ease. To accomplish 
this purpose moulded splints of plaster may be made by cutting a paper 
pattern of the part to be covered in, and then cutting pieces of crinoline 
to conform to this pattern ; eight or ten pieces will usually form a splint 
of sufficient thickness. One of these pieces of crinoline is laid upon a 
table and dry plaster is rubbed into its meshes ; another is laid upon this 
and plaster is applied to it in the same way ; and so on until all the 
pieces have been placed in position, one over the other, with plaster 
rubbed well into the meshes. The dressing is then folded up and dipped 
into water, squeezed out, and moulded to the part and held in position, 
by the turns of a bandage, until it sets. The edges should slightly 
overlap each other, and in applying it a strip of waxed paper may be 
placed under the overlapping edges to prevent its adhesion to the sur- 
face below, and this facilitates its removal. Splints prepared in this 
way can be removed with ease, and are often of service in cases where 
it is desirable to inspect the parts frequently. The author has employed 
with advantage such splints in making fixation of the hip-joint in cases 
of coxalgia, and also for the same purpose in atfections of other joints. 
Splints upon being reapplied are secured by a few strips of bandage or 
by a roller bandage. 

Trapping Plaster-of-Paris Bandages. — It is often necessary to make a 
trap or fenestrum in the plaster-of-Paris bandage which has been applied 
to a part where there is a wound which requires inspection or dressing. 
In applying the bandage it is well to make some provision whereby the 
plaster-of-Paris dressing over the seat of the wound may be cut away. 
To accomplish this, before applying a plaster-of-Paris bandage a com- 
press of lint or gauze should be placed over the wound, which, when the 




dressmg is completed, forms a projection on its surface indicating the 
position of the wound, and also allows the surgeon to cut away the 
plaster dressing without injury to the skin below (Fig. 74). These traps 



HARDENING BANDAGES. 



63 



may be cut out with a knife after the bandage has partially set or after 
it has become hard. In applying a plaster-of-Paris dressing in cases 
of compound fracture and after osteotomy it is always well to make pro- 
vision for trapping the bandage if it should become necessary, although 
in the vast majority of cases it does not need to be done. 

Removing Plaster-of-Pm-is from the Hands. — One objection to the use 
of plaster-of-Paris dressings is the difficulty of removing the plaster 
from the hands of the surgeon, and the harsh condition in which the 
skin of the hand is left after its removal. If, however, the hands are 
washed in a solution of carbonate of sodium — a tablespoonful to a basin 
of water — the plaster will be readily removed, and the skin will be left 
in a soft and comfortable condition. 

Removal of the Plaster-of-Paris Bandage. — The removal of the plas- 
ter-of-Paris bandage is sometimes a matter of difficulty, particularly if 
it has to be removed before the parts below have become consolidated, 
as it may disarrange them and cause the patient pain if it is not accom- 
plished without much force. 

When the bandage is applied to get a cast of the part, or in the 
treatment of fractures where it may be desirable to remove it within a 
few days, a strip of sheet lead one inch in width is first placed over the 
flannel bandage, and is allowed to project at each end beyond the dress- 
ing ; after the plaster bandage has been applied and before it has quite 
set it can be readily cut through upon this strip with a knife without 
injury to the parts below, and the cast can be removed as soon as it is 
firm. It may also be removed by means of a saw devised for this pur- 

FiG. 75. 




Saw for removing plaster-of-Paris bandage. 



pose (Fig. 75), or by strong cutting shears of various kinds (Fig. 76), 
or a line may be painted over the dressing with hydrochloric acid or 



Fig. 76. 




Shears for cutting plaster-of-Paris bandage. 

vinegar, which softens the plaster so that it can be readily cut through 
with a knife. Dr. William B. Hopkins has devised a vertebrated metal 
chain which is applied to the part before the plaster is applied, and 
removed when the bandage has set, leaving a hollow longitudinal ridge 
which can be cut through or divided with a rasp. The use of the saw 
or shears is the most satisfactory method to remove these dressings ; the 
only caution to be exercised is to use them carefully as the final layers 
of the bandage are divided, to avoid wounding the skin. 



64 MINOR SUBGEBY. 

Uses of the Plaster-of-Paris Dressings.— Phster-of-Faris dressings are 
employed to secure fixation, as primary or secondary dressings in the 
treatment of fractures, and for a like purpose in injuries or diseases of 
the joints. They are also largely used in the treatment of diseases of 
the spinal column, and will also be found the most satisfactory dressing 
after osteotomy and tenotomy to secure immobility and hold the parts in 
their corrected positions ; when employed in the dressings of cases after 
tenotomy they are generally used for a few weeks until the proper me- 
chanical apparatus is applied. 

The Starched Bandage. — In the application of this bandage starch 
is first mixed with water until a thick creamy mixture results ; to this 
is added boiling water until a clear mucilaginous liquid is produced ; if 
too thin, it can be made thicker by heating for a few minutes. The 
part to be dressed is first covered with a flannel roller, and over this a 
few layers of cheese-cloth or crinoline, which has been shrunken, are 
applied : the starch is then smeared or rubbed with the hand evenly into 
the" meshes of the material, and the part is again covered with a layer 
of turns of the bandage, and the starch is again applied ; this manipula- 
tion is continued until a dressing of the desired thickness is produced. 
Strips of pasteboard may be applied betw^een the layers of the bandage 
to give additional strength to the dressing if desired. It requires from, 
twenty-four to thirty-six hours for the starched bandage to become dry 
and thoroughly set, which is a decided disadvantage in its employment. 

A starched bandage may be removed in the same way in which the 
plaster-of-Paris dressing is removed. Before the introduction of the 
plaster-of-Paris dressing the starched bandage was much employed as a 
means of fixation in the treatment of fractures and injuries of the joints. 
It may be used in such cases, but possesses no advantage over the former 
dressing, and has the disadvantage of setting much less promptly. 

Gum-and-chalk Bandage. — In the application of this dressing 
equal parts of powdered gum arable and precipitated chalk are mixed 
with boiling water until a mass of the consistence of thick cream re- 
sults. This is applied to the cheese-cloth or crinoline bandage in the 
same manner as the starch in the application of the starched bandage : 
it has the advantage over the latter dressing of setting more promptly, 
five or six hours only being required for it to become hard. It may be 
employed for the same purpose as the starched or plaster-of Paris band- 
age. 

Silicate-of-Potassium or Sodium Bandage. — In the application of 
this bandage, after the flannel roller and several layers of cheese-cloth 
or crinoline bandage have been applied to the part, the surface of the 
latter is coated with silicate of sodium or potassium applied by means 
of a brush ; then a second layer of crinoline bandage is applied and 
treated in the same manner, and this manipulation is continued until a 
bandage of the desired thickness is produced. It requires twenty-four 
hours for this dressing to become firm. In removing the silicate band- 
age it may be first softened by soaking it in warm water, and it then 
can be readily cut with scissors. 

In applying either the starched bandage or the silicate-of-potassium 
bandage care should be taken to use cheese-cloth or crinoline which has 
been shrunken by being moistened and allowed to dry before being em- 



MOULDED SPLINTS. 



65 



ployed ; otherwise dangerous compression of the part may occur if the 
bandage has been firmly applied and shrinks after its application. 

The Paraflfin Bandage. — Paraffin, which melts at from 105° to 120° 
F., is employed in the application of a fixed dressing. The limb being 
covered by a flannel roller, a vessel containing paraffin is placed in a 
basin of boiling water ; as the bandage, which may be either of flannel, 
cheese-cloth, or crinoline, is unwound, it is passed through the melted 
paraffin and applied to the part, and the turns are repeated until a 
dressing of sufficient thickness results, and the surface may be brushed 
over with melted paraffin. This dressing sets very rapidly, being quite 
firm in from five to ten minutes. It possesses the advantage over the 
other fixed dressings in that it does not absorb discharges and become 
ofiensive, and for this reason it was formerly recommended in the forma- 
tion of a fixation splint in the treatment of compound fractures. 

Glue or Glue-and-Oxide-of-zinc Bandages. — Glue or glue com- 
bined with oxide of zinc has been employed in the preparation of fixed 
dressings, but possesses no advantage over those previously mentioned. 

In the application of this bandage glue which has been dissolved in 
boiling water is brushed over the surface of a crinoline roller applied to 
the part, or there may be added to the solution of glue oxide of zinc. 
The glue bandage becomes hard more promptly than the starched band- 
age, but does not form so strong a dressing as the starched, silicate-of- 
sodium, or plaster-of-Paris bandage. 



Eaw-hide or Leather Splints for Dressings. 



Fig. 77. 



In ajjplying raw-hide or leather splints it is necessary first to apply a 

plaster-of-Paris bandage to the part to which 
the raw-hide dressing is fitted, and as soon 
as the plaster has set it is removed, and a 
solid plaster cast is next made by pouring 
liquid plaster-of-Paris into the mould thus 
obtained. When this has become dry a 
piece of raw-hide, which has been soaked 
for some hours in warm water, is moulded 
to the cast, and is firmly held in contact 
with it by means of a bandage or by tacks 
until it has become perfectly dry, which 

Fig. 78. 




Leather jacket with jury-mast. 
Vol. IL— 6 




Leather splint for cervical caries (Owen). 



66 



MINOR SUBOEBY. 



Fig. 79. 



usually requires several days. It is then removed, and its surface is cov- 
ered with several coats of shellac to prevent its absorbing moisture from 
the skin when applied and changing its shape. Eyelets or hooks are 
fastened to the edges of the splints, through which strings are passed to 
secure it in place. 

Raw-hide splints prepared in this manner fit the part very accurately 
and constitute a veiy satisfactory dressing for cases of joint disease, and 
in the form of leather jackets are often employed in the treatment of 
disease of the spine in place of the plaster-of-Paris jacket (Figs. 77, 
78). 

Binder's-board or Pasteboard Splints. — Binder's board, which can 
be obtained in sheets of different thickness, is frequently employed for 
the manufacture of splints. A portion of board of the requisite size and 
thickness is dipped in boiling water for a short time, and when it has 
become softened it is removed and allowed to cool ; a thick layer of 
cotton batting is next applied over it, and it is then moulded to the part 
and held firmly in place by the turns of a roller bandage ; in a iew 
hours it becomes dry and hard. 

This material, from its cheapness and the ease with which it is 
obtained, is frequently employed to mould splints for the treatment of 

fractures, especially in children, 
and for the fixation of joints in 
the treatment of acute and chronic 
joint affections (Fig. 79). A 
moulded binder's-board splint is 
often employed to fix the ends of 
the bones after the excision of a 
joint. 

Porous Pelt Splints. — This 
material is also employed for the 
manufacture of splints, and is ap- 
plied by dipping the material in 
hot water and then moulding it to 
the part ; as it dries it becomes 
hard. 

Hatter's-felt Splints. — Hat- 
ter's felt is sometimes employed 
for the manufacture of splints or 
dressings. It is softened by dip- 
ping it in boiling water or heating 
it in the flame of an alcohol lamp, 
and when soft and pliable it is 
moulded to the part, and as it 
cools it again becomes hard. 

Gutta-percha Splints. — These 
splints or dressings are made from sheets of gutta-percha from one-six- 
teenth to_ one-eighth of an inch in thickness. This material is cut into 
the requisite shape, and is prepared for moulding by immersing it in 
hot water, when it becomes soft and can be moulded to the surface. 
Care should be taken that it is not allowed to become too soft, by too 
long immersion, to permit its being conveniently handled. 




''iiiliiP"'* 

Moulded binder's-board splints. 



MATERIALS USED IN SURGICAL DBESSINOS. 67 

Materials Used in Surgical Dressings. 

Lint. — This material is employed in surgical dressings, and is of two 
varieties — the domestic lint, which consists of pieces of old linen or 
muslin which have been thoroughly washed or boiled and then dried, or 
the surgical lint, which is manufactured by machinery and resembles 
canton flannel in appearance ; the latter is the best material, as it has a 
greater absorbing capacity. 

Lint is used as a material on which unctuous preparations are spread 
in the dressings of wounds, and is also employed as a material for satu- 
rating with the various solutions which are used in wet dressings, such 
as lead-water and laudanum, or dilute alcohol. The lint, after being sat- 
urated with these solutions, may be covered with rubber tissue or oiled 
silk when applied, to prevent too rapid evaporation of the solution. It 
is also one of the best materials from which to construct compresses em- 
ployed in the treatment of fractures, to control hemorrhage, or to make 
pressure for any purpose. 

Paper Lint. — Paper lint, made from wood-pulp, is also employed 
in surgical dressings, as it has great absorbing power for fluids, and it 
may be used as a substitute for surgical lint in the application of wet 
dressings. 

Oakum. — Oakum, which is made from old tarred rope, was formerly 
much employed for dressing of wounds before the introduction of the 
antiseptic method of wound-treatment. From its elasticity it is found to 
be an excellent material for padding splints or other surgical appliances. 
It is also employed in the form of pads to place under patients to relieve 
portions of the body from pressure or to absorb discharges which soak 
through the dressings. A mass of oakum which has been well teased 
out and wrapped in a towel forms an excellent pillow on which to sup- 
port a stump. 

The oakum seton is highly recommended by Dr. Sayre as a means of 
making a direct application of dressings to sinuses of bone : the oakum 
is loosely twisted into a cord and covered with any ointment desired, and 
is passed through the sinuses in the bone ; the position of the seton is 
changed from time to time, fresh ointment being applied before it is 
drawn through. 

Cotton. — Cotton is now employed in surgical dressings, principally as 
a material to pad splints or to relieve salient parts of the skeleton from 
pressure in the application of splints or bandages ; for instance, in the 
application of plaster-of-Paris bandages the bony prominences are gen- 
erally covered by small masses of cotton ; it possesses but little absorbent 
power unless used in the form of absorbent cotton, and is not much em- 
ployed in surgical dressings except for the purposes mentioned above. 

Absorbent Cotton. — This material is prepared from ordinary cotton, 
which is boiled with a strong alkali to remove the oily matter which it 
contains. When so prepared it absorbs liquids freely, and for this reason 
is largely employed in surgical dressings. A small mass of absorbent 
cotton wrapped on the end of a probe or stick is now generally employed 
to make applications to wounds, and has taken the place of the sponge 
or brush which was formerly employed for this purpose. From its 
cheapness, after one application it can be thrown away and a new piece 



68 MINOR SURGERY. 

can be used, and thus the danger of carrying infection from one wound 
to another by the applicator is abolished. It is largely employed in gyne- 
cological practice for making applications to the female genital organs. 

When impregnated with various antiseptic substances, such as bi- 
chloride of mercury, carbolic acid, boric acid, and salicylic acid, absorbent 
cotton forms the bichloride, carbolized, borated, and salicylated cotton so 
much used in antiseptic dressings. 

Jute. — This substance is made from the fabric of the Corchorus eap- 
sularis, which, on account of the character of its fibre, possesses both 
elasticity and absorbent qualities : it has been employed for much the 
same purposes as oakum and cotton, such as the padding of splints, and 
is also used as an external absorbent dressing. 

Wood-wool. — Wood-wool, made from wood-pulp, such as is employed 
in the manufacture of paper, is also furnished in the shape of lint, sponges, 
and pads, and may be used for the same purposes in surgical dressings, 
in place of surgical lint or the ordinary sponges or pads. 

Oiled Silk and Muslin. — These materials are employed as an external 
covering for moist dressings to prevent rapid evaporation from the dress- 
ings ; they form excellent materials for this purpose, but, as they are 
quite expensive, their use is limited. 

Waxed or Paraffin Paper. — This dressing is prepared by passing 
sheets of tissue-paper through melted wax or paraffin, and then allowing 
them to dry for a few minutes. Paper thus treated forms an excellent 
and cheap substitute for oiled silk and oiled muslin, and may be employed 
for the same purposes for which these materials are used. 

Rubber Tissue. — This material consists of rubber run out into very 
thin sheets ; it has a glazed surface, is very pliable and strong, and forms 
a cheap and satisfactory substitute for oiled silk, being employed for the 
same purposes. In the moist method of antiseptic dressing it may be 
used in place of the macintosh. 

Parchment Paper. — This is a very tough paper material which can 
be soaked in a solution of, corrosive sublimate or carbolic acid without 
becoming so much softened as to tear upon handling, and it is employed 
for the same purposes as macintosh. 

Protective. — Protective is employed to prevent the wound from 
being irritated by antiseptic substances with which the gauze is impreg- 
nated or by its irregular surface. Various materials are employed as 
protectives, the principal requirement being that the tissue can be readily 
rendered aseptic and does not absorb any irritating materials from the 
dressings. The protective first employed by Lister, which is still gen- 
erally used, is prepared by coating oiled silk with copal varnish, and when 
this is dry a mixture of 1 part of dextrin, two parts of powdered starch, 
and 16 parts of a 1 : 20 carbolic solution is rubbed over its surface. 
Rubber tissue may be employed very satisfactorily as a substitute for this 
protective. 

Macintosh.— This consists of cotton cloth with a thin layer of india- 
rubber spread on one side. It is employed in antiseptic dressings as a 
layer outside of the gauze, and should be applied with the rubber surface 
toward the wound, to prevent the entrance of air, and to allow the serum 
from thewound to permeate the gauze and not to soak directly through 
the dressings. " ° 



MATERIALS USED IN SURGICAL DRESSINGS. 69 

Rubber Dam. — This is a thin pure rubber tissue, and, as it has no 
cloth surface Hke macintosh, it is cleaned and sterilized with greater 
facility. It is used in applying the moist method of dressing to cover 
the gauze dressings, and is attached to a drainage-tube in abdominal 
wounds to shut off the opening of the drainage-tube from the abdominal 
wound. Before being used it should be washed with soap and water and 
rinsed, and then placed in a solution of carbolic acid for a short time. 

Gauze Dressings. — The most convenient and cheapest material for 
wound-dressing is a sheer material known to the trade as cheese- or 
tobacco-cloth. By reason of having a very open mesh it absorbs well 
either the materials with which it is prepared or the discharges from the 
wound. It can be readily obtained anywhere, is inexpensive, and is soft 
and pliable, so that it is a comfortable dressing to the patient. 

In the preparation of cheese-cloth to form the gauze dressings it is 
first placed in a vessel and covered with water, to which is added wash- 
ing soda or lye, and is boiled ; the soda or lye is added to remove any 
oily matters which the cheese-cloth contains, thus making it more absorb- 
ent. After the cheese-cloth has been boiled it is washed and passed 
through a clothes-wringer, and is then impregnated with some of the 
various substances which are used to render it antiseptic, or it may be 
dried and baked in an oven and be used as the simple sterilized gauze. 

Compresses. — Compresses are prepared by folding pieces of linen or 
flannel upon themselves, so as to form masses of various sizes ; oakum 
or cotton may also be used for compresses. Compresses are employed 
to make pressure over localized portions of the body, as in the treat- 
ment of fractures, or to make pressure on vessels for the control of 
hemorrhage. 

Tampon. — A tampon is a form of compress which is employed in 
cavities to make pressure, to control hemorrhage, or to apply various 
medicines to the surface of a cavity. Tampons made to control hemor- 
rhage are generally made of strips of bichloride or iodoform gauze or 
of pledgets of bichloride cotton. In applying this the strips of cotton 
are packed into the cavity, and when the cavity is full a compress is 
apphed superficially and held in place by a bandage. 

A glycerin tampon, employed as an application to the os uteri, may be 
made by pouring half an ounce of glycerin on a piece of cotton or wool 
and then turning up the ends and securing them by a string, one end of 
which is allowed to remain long to hang from the vagina to facilitate its 
removal. 

Tent. — This consists of a small portion of lint, oakum, or muslin 
rolled into a conical shape, and is employed to keep wounds open and 
to facilitate the escape of discharges. This dressing is not much em- 
ployed at the present time, its use being largely superseded by the 
drainage-tube. 

Retractors. — Retractors are made by taking a piece of muslin four 
inches wide and twelve to eighteen inches in length, and splitting it as 
far as the centre, thus making a two-tailed retractor (Fig. 80). A three- 
tailed retractor is made by making two splits in the fabric (Fig. 81). 

Plasters. — The varieties of plasters which are most commonly em- 
ployed in surgical dressings are adhesive or resin plaster, isinglass plaster, 
rubber adhesive plaster, and soap plaster. 



70 



MINOR SURGERY. 



Besin Plaster.— This plaster, which is machine-spread, is one of the 
most widely-employed plasters in surgical dressings : the spread surface 
is covered with a layer of tissue-paper, which should be removed before 



Fig. 80. 



Fig. 81. 




■;,,,. ■ . ,.,,:..:- '^^""Wms^'^&s^ 


l'--;:::;iii 


V-'" 


':jlt:,:v'-j:;lB 


\ ^Z- 


■?■••.:: ■■■ ' ■ 


\ W- I 










V^: 1 ■ :':'■ 


V /" ; 


\!L_ 1.. _iit 


\|S':-:;'r: 



Two-tailed retractor. 



Three-tailed retractor. 



it is used, and the strips should be cut lengthwise from the roll, as the 
cloth upon which it is spread stretches more transversely than in a 
longitudinal direction. When heated and applied to the surface it holds 
firmly ; it is prepared for application by applying the unspread side to a 
vessel containing hot water, or it may be passed rapidly through the 
flame of an alcohol lamp. 

This is the plaster generally used in maldng the extension apparatus 
for the treatment of fractures, for strapping the chest in fractures of the 
ribs and sternum, for strapping the pelvis in cases of fractures of the 
pelvic bones, or for strapping the breast, the testicle, ulcers, or joints. 

Rubber Adhesive Plaster. — This plaster is made by spreading a 
preparation of india-rubber on muslin, and has the advantage over the 
ordinary resin plaster that it adheres without the application of heat. 
It is employed for the same purposes as resin plaster, but when applied 
continuously to the skin it is apt to produce a certain amount of irrita- 
tion, and for this reason, when it is to be applied for some time, as in 
the case of an extension apparatus, it is not so comfortable a dressing as 
that made from resin plaster. 

Isinglass Plaster. — This plaster, whicli is made by spreading a solu- 
tion of isinglass upon silk or muslin, will be found the most useful dress- 
ing in the treatment of superficial wounds. It is made to adhere to the 
surface by moistening it, and Avhen used in the treatment of wounds it 
should be moistened with an antiseptic solution : it is in this way ren- 



MATERIALS USED IN SURGICAL DRESSINGS. 71 

dered aseptic, and may be used with safety in connection with other 
aseptic dressings. The best form of this plaster is spread on muslin, 
and when properly applied adheres as firmly and possesses as much 
strength as the ordinary resin plaster. 

Before using any of these plasters, if the part to which they are to 
be applied contains hairs, these should be shaved off, otherwise traction 
upon these, if the plaster is used for the purpose of extension, or in its 
removal, will cause the patient discomfort or pain. 

8oap Plaster. — This plaster for surgical purposes is prepared by spread- 
ing emplastrum saponis upon kid or chamois. It has little adhesive power, 
and is used simply to give support to parts or to protect salient portions 
of the skeleton from pressure. It is found a most useful dressing when 
applied over the sacrum in cases of threatened bed-sores, and may be 
applied for the same purpose to other parts of the body where pressure- 
sores are apt to occur. 

In the treatment of joints a well-moulded soap-plaster splint secured 
by a bandage Avill often be found a most efficient dressing, and in the 
treatment of fractures the comfort of the patient is often materially 
increased by applying a piece of soap plaster over the bony prominences, 
upon which the splints, even when well padded, are apt to make an undue 
amount of pressure. 

Strapping. — The application of pressure to parts by means of strips 
of plaster firmly applied is a procedure often employed in surgical 
practice. 

Strapping the Testicle. — In strapping the testicle strips of resin 
plaster are usually employed; a dozen or more strips, three-quarters 
of an inch in width and twelve inches in length, will be required. 
The scrotum should be first washed and shaved, and the surgeon then 
draws tlie skin over the aifected organ tense by passing the thumb and 
finger around the scrotum at its 
upper portion, making circular con- 
striction. A strip of plaster which 
has been heated is passed in a circu- 
lar manner around the skin of the 
scrotum above the organ, and is 
tightly drawn and secured ; this iso- 
lates the part and prevents the other 

strips from slipping. Strips are now ^^^^^^.^^ the testicle (Smith). 

employed in a longitudinal direction, 
the first strip being fastened to the circular strip and carried over the 
most prominent portion of the testicle (Fig. 82), and is then carried 
back to the circular strip and fastened. A number of these strips are 
applied in an imbricated manner until the skin is covered in (Fig. 82), 
and the dressing is completed by passing transverse strips around the 
scrotum from its lowest portion to the circular strip ; care should be 
taken to see that no portion of the skin is left uncovered. 

Strapping the testicle is employed with advantage in the subacute 
stage of orchitis or epididymitis, and is a useful means of applying 
pressure to the scrotum after the injection treatment of hydrocele. As 
the swelling of the testicle diminishes the strips become loose and the 
parts require restrapping. 




72 



MINOR SURGERY. 



Fig. 83. 




Strapping the breast (Smith). 



Strapping the Breast. — In strapping the breast, strips of resin plaster, 
two inches in width and long enough to pass from the opposite shoulder 
under the breast to the point of starting, are required. In applying it 
the end of the strip is placed on the spine of the scapula on the side 

opposite the diseased breast, is carried for- 
ward over the shoulder and obliquely down- 
ward under the breast and axilla, and then 
over the back to the point of starting ; the 
next strip is applied in the same direction, 
overlapping about one-third of the pre- 
vious strip (Fig. 83) ; these oblique strips 
are applied in an imbricated manner until 
a sufficient number have been used to cover 
in the breast, or the oblique strips may be 
alternated with circular strips passing from 
the sternum over the breast to the spine. 
A sufficient number of strips are used to 
cover the breast and make firm compression upon it. 

Strapping the breast in this manner will be found a satisfactory 
method of treatment in chronic inflammatory conditions of the breast, 
where it is of advantage to support the breast and make compression 
at the same time ; it has the advantage over the use of a bandage to 
support and compress the breast in that it does not interfere with the 
chest motions upon the opposite side of the body. 

Strapping the Chest. — To strap one-half of the chest strips of resin 
plaster, two and a half inches in width and long enough to extend from 
the spine to the median line of the sternum — eighteen to twenty inches 
in length — will be required. One extremity of a strip is placed upon 
the spine opposite the lower portion of the chest ; 
it is then carried over the chest, and its other 
extremity is fixed upon the skin in the median 
line of the sternum. Strips are next applied from 
below upward in the same manner, each strip 
overlapping one-third of the preceding one, until 
the axillary fold is reached (Fig. 84) ; a second 
layer of strips may be applied over the first if 
additional fixation is desired, or a few oblique 
strips may also be employed. Adhesive strips 
applied in this manner very materially limit the 
motion of the chest-wall upon the affected side, 
and are frequently employed in the treatment of 
fractures and dislocations of the ribs, in contusions of the chest, and in 
cases of plastic pleurisy where the motions of the chest-Avalls are 
extremely painful to the patient. 

Strapping of Ulcers. — To strap ulcers of the leg, strips of resin 
plaster, two inches wide and long enough to extend two-thirds around 
the limb, are required. The ulcer should be thoroughly cleansed and 
the skin surrounding it should be well dried: the first strip, being 
heated, is applied obliquely to the long axis of the leg about two inches 
below the ulcer, and is carried two-thirds around the limb ; another 
strip is applied to a corresponding point of the skin on the opposite 



Fig. 84. 




Strapping the chest. 



STRAPPING. 73 

side of the limb and is carried obliquely over the limb, crossing the 
first strip in the median line, and is carried two-thirds of the way 
around the leg ; alternate strips are then applied until the ulcer is 
covered in, and the strips are carried several inches above the ulcer 
(Fig. 85). Care should be taken that the strips are so applied as 

Fig. 85. 




strapping ulcer of leg (Listen). 

not to meet or cover the entire circumference of the limb, as by so 
doing injurious circular compression may result. Chronic ulcers upon 
other portions of the body may be strapped in the same manner. 

The strapping of leg ulcers is usually reinforced by the application 
of a spiral reversed or spica bandage of the lower extremity. Strap- 
ping of ulcers of the leg in the manner described will be found a most 
satisfactory method of treating chronic ulcers in this location in patients 
who have to work during the course of treatment : the strips need only 
be removed at intervals of a week, and, if well applied, the dressing is 
generally a comfortable one to the patient. 

Strapping of Joints. — Strips of resin plaster, two inches in width 
and long enough to extend two-thirds around the joint, are required. 
The first strip is applied about two inches below the joint, and strips are 
then applied above this, each strip covering in two-thirds of the pre- 
ceding one until the joint is covered in and the strips extend a few 
inches above the joint. 

The ankle-joint is strapped by taking strips of resin plaster one and 
a half inches in width : the first strip is placed over the heel, and its 
ends are brought forward until they meet over the dorsum of the foot ; 
a second strip encircles the foot and secures the ends of the first strip. 
The strips are alternately applied, each strip covering one-half of the 
previous strip until the foot and ankle are covered. 

Strapping of joints will be found a satisfactory dressing in the treat- 
ment of sprains of joints in their chronic state. 

Strapping of a Carbuncle. — To strap a carbuncle strips of resin plaster 
one to one and a half inches in width are required. These' strips are 



74 MINOR SURGERY. 

applied to the margin of the swelling, and are laid on concentrically 
until all except the central portion are covered in ; if a number of open- 
ings exist, the strips are so placed as not to cover these. Strapping 
applied in this manner in the treatment of carbuncle is often a com- 
fortable dressing to the patient, and at the same time the concentric 
pressure favors the extrusion of the sloughs. 

Poultices. — This form of dressing was formerly much employed in 
the treatment of local inflammatory conditions, or in wounds, as a means 
of applying heat and moisture to the part at the same time, and, although 
the use of poultices is now very much restricted since the introduction 
of the antiseptic method of wound-treatment, there are still conditions 
in which their employment is both useful and judicious. 

Poultices are often employed with advantage in inflammatory affec- 
tions of the chest and abdominal organs ; and in inflammatory affections 
of the joints and of bone their action, combined with rest, is often most 
satisfactory ; in cases of gangrene their employment hastens the separa- 
tion of the sloughs. They constitute a form of dressing which conduces 
much to the comfort of the patient in cases of deep suppuration by their 
relaxing effect upon the tissues, and their previous use does not prevent 
the surgeon from using all antiseptic precautions in the opening and 
drainage of these abscesses and the employment of antiseptic dressings 
in their subsequent treatment. 

Flaxseed Poultice. — ^This poultice is prepared by adding a little 
warm water to ground flaxseed, and then adding boiling water and 
stirring it until the resulting mixture is of the consistency of thick 
mush. A piece of muslin is next taken, which is cut a little larger 
than the intended poultice, and this is laid upon the surface of a table, 
and the poultice mass is spread evenly upon it from a quarter to a half 
inch in thickness with a spatula or knife ; a margin of the musKn of 
one and a half inches is left, which is turned over after the poultice is 
spread, and serves to prevent it from escaping around the edges when 
applied. The surface of the poultice may be evenly spread over with a 
little olive oil or may be covered with a layer of thin gauze to prevent 
the mass from adhering to the skin. It is next applied to the surface 
of the skin, and is covered with a piece of oiled silk, rubber tissue, or 
waxed paper, and is held in position by a bandage or a binder. 

Bread Poultice.— This poultice is prepared from stale wheaten bread, 
the crusts being discarded and the crumbs only being used ; this is 
moistened with boiling water and allowed to soak for a few moments, 
when the excessive moisture is poured off and the mass is spread upon a 
piece of muslin or linen, as before described. 

Starch Poultice. — This poultice is prepared by mixing starch with 
cold water until a smooth, creamy fluid results ; boiling water is then 
added, and it is heated until it becomes clear and it has about the same 
consistency as the starch used for laundry purposes. When sufficiently 
cold it is spread upon muslin and applied to the part, and covered with 
oded silk or waxed paper. This variety of poultice is principally used 
in cases of disease of the skin, especially those of the scalp accompanied 
by the formation of scales or crusts, to facilitate their removal and to 
furnish a clean surface for the application of ointments or wet dressings. 

Charcoal Poultice.— In preparing this poultice flaxseed meal and 



POULTICES. 75 

powdered charcoal are mixed together, and by adding boiHng water a 
poultice mass is produced which is spread upon muslin as previously 
detailed. It is better to use animal charcoal in making this poultice, as 
it has greater deodorizing power than the vegetable charcoal. This 
poultice is used as an application to gangrenous parts, as it possesses 
marked deodorizing properties. 

Fermenting Poultice. — This poultice may be prepared by adding yeast, 
two tablespoonfuls^ to a mixture of flaxseed with hot water, making a 
thin poultice mass, and allowing it to stand for a few hours in a warm 
place ; it rises and becomes light, and is then spread upon muslin and 
applied as required. A few ounces of porter or a piece of yeast-cake 
may be used as a substitute for the yeast in preparing this poultice ; 
charcoal may also be added to it to increase its disinfectant power. This 
poultice was formerly, and is still, used as an application to gangrenous 
parts to hasten their separation and to diminish the odor arising from the 
necrosed tissues. 

Oakum Poultice. — This poultice is prepared by soaking a mass of 
loosely-picked oakum in hot water, wringing it out, and covering it 
with a layer of cheese-cloth or antiseptic gauze. It is next applied to 
the part and covered with oiled silk or rubber tissue, and held in place 
by a bandage ; it has a large capacity for the absorption of discharges. 
It may be wrung out in a warm bichloride or carbolic solution, and thus 
form an antiseptic poultice. 

Hot Fomentations. — Hot fomentations are employed to keep up the 
vitality of parts which have been subjected to injury, as seen in severe 
contusions or lacerations resulting from railway or machinery accidents ; 
also to combat inflammatory action. Flannel cloths, several layers in 
thickness, or surgical lint, should be soaked in water having a tempera- 
ture of 120° F. ; these are wrung out and placed over the part and covered 
with waxed paper or rubber tissue ; a second cloth should be placed in 
hot water, ready to apply as soon as the first-applied cloth begins to 
cool, and so by continuously reapplying them the part is kept constantly 
covered by a hot dressing. The use of these hot fomentations may in 
many cases have to be continued for hours before the desired result is 
obtained. Hot compresses applied in this manner are frequently em- 
ployed in treating inflammatory conditions of the eye, and are also of 
the greatest service in keeping up the vitality of parts which have been 
subjected to severe injury interfering with their blood-supply. The 
writer has frequently seen contused limbs, which were cold and seemed 
to be doomed to gangrene by reason of their diminished blood-supply, 
have their temperature and circulation restored by the patient and per- 
sistent use of this dressing. After the vitality of such a part is restored 
it should be covered with cotton and a flannel bandage alid surrounded 
by hot- water bags or hot^ water cans. 

Irrigation. — ^This may be accomplished by allowing the irrigating 
fluid to come directly in contact with the wound or inflamed part, which 
is known as immediate irrigation, or by allowing the cold or warm fluid 
to pass through rubber tubes which are in contact with or surround the 
part; the latter method is known as mediate irrigation. 

Immediate Irrigation. — In applying immediate irrigation in the treat- 
ment of wounds or in inflammatory conditions a funnel-shaped can with 



76 



MINOR SURGERY. 



a stop-cock at the bottom, or a bucket, is suspended over the part at a 
distance of a few inches (Fig. 86), or a jar with a skein of thread or 



Fig. 86. 




Apparatus for continuous irrigation (Esmarch). 



lamp-wick arranged to act as a siphon may be employed (Fig. 87). The 
can or jar is filled with water, and this is allowed to fall, drop by drop, 

Fig. 87. 




Irrigating apparatus (Erichsen). 



upon the part to be irrigated, which should be placed upon a piece of 
rubber sheeting so arranged as to allow the water to run off in a recep- 



IBBIGATION. 



11 



tacle, so as to prevent the wetting of the patient's bed. The water 
employed may be either cold or warm, and this is decided by the indica- 
tions in special cases, and if it is desired to make use of antiseptic irri- 
gation, the water is impregnated with carbolic acid or bichloride of mer- 
cury, a 1 : 5000 to 1 : 10,000 bichloride solution, or a 1 : 60 carbolic acid 
solution is frequently employed with good results. 

Antiseptic irrigation employed in this manner will be found a most 
useful method in treating lacerated and contused wounds of the extremi- 
ties in which the vitality of the tissues are impaired, and in such cases 
warm water should be preferred to cold water, the temperature being 
from 100° to 110° F. Under the use of warm irrigation it is surprising 
to see how tissues apparently devitalized regain their vitality. The 
absence of tension from the non-introduction of sutures or firm dressings, 
and the warmth and moisture kept constantly in contact with the wound 
by this method of treatment, are the important factors in the attainment 
of this favorable result. 

Mediate Irrigation. — In applying mediate irrigation cold or warm 
water is passed through a rubber tube in contact with the part. A 
flexible tube of india-rubber half an inch in diameter, with thin walls, 
and sixteen or twenty feet in length, is applied to the limb like a spiral 
bandage or is applied in a coil to the head, breasts, or joints, and is held 
in place by a few turns of a bandage (Fig. 88). The end of the tube 



Fig. 88. 




Mediate irrigation (Esmarch). 

is attached to a reservoir filled with cold or warm water above the level 
of the patient's body, and the water is allowed to flow constantly through 
the tube and escape into a receptacle arranged to receive it. 

Cold-water Dressings. — These dressings are applied by bringing the 
cold water either directly in contact with the part or by applying it by 
means of a rubber bag or bladder. The temperature of the water may 
be varied from cool water to that of ice-water. 

These dressings are employed in local inflammatory conditions : a 



78 MINOR SURGERY. 

favorite method is by means of cold compresses, which are made of a few 
layers of surgical lint dipped in water of the desired temperature and 
applied to the part ; they are renewed as soon as they become warm. 
When it is desired to have the compresses very cold, they may be laid 
upon a block of ice or in a basin of broken ice. To obtain the best re- 
sults from their employment they should be renewed at very short 
intervals. 

Ice-bag. — A very convenient method of applying cold without moist- 
ure is by the use of the ice-bag. This is either a rubber bag or a bladder 
which is filled with broken ice and applied to the part. In using the 
ice-bag it is better to cover the part first with a towel or a few layers of 
lint or muslin, which prevents the surface from becoming wet by absorb- 
ing the moisture which condenses upon the surface of the bag or bladder, 
and thus renders the dressing more comfortable to the patient. The ice- 
bag is often employed as an application to the head in inflammatory con- 
ditions of the brain or membranes, and is also used upon the surface of 
the body to control internal hemorrhage. 

COUNTBK-IEEITATION. 

Counter-irritants are substances employed to excite external irrita- 
tion, and the extent of their action varies according to the materials 
used and duration of its application : superficial redness or complete 
destruction of the vitality of the parts to which they are applied may 
result. The use of counter-irritants under favorable circumstances is 
found to have a decided effect in modifying morbid processes, and they 
are widely employed as local revulsants in cases of congestion or inflam- 
mation, and in cases of collapse for their stimulating effect. 

Rubefacients. — These agents, by reason of their irritating properties 
when applied to the skin, produce intense redness and congestion. 

Hot Water. — When it is desired to make a quick impression on the 
skin, the application of muslin or flannel cloths wrung out in hot water 
and renewed as rapidly as they become cool will soon produce a super- 
ficial redness of the integuments. 

Spirits of Turpentine. — This drug, applied to the skin, is a very 
active counter-irritant ; it may be rubbed upon the surface of the skin 
until redness results. When used upon patients whose skin is very 
delicate, its action may be modified by mixing it with equal parts of 
olive oil before applying it ; this will be found a useful precaution in 
applying it as a rubefacient to the tender skins of young children. 
When redness of the skin has resulted from the application, the skin 
should be wiped dry by means of a soft towel or absorbent cotton to 
remove from the surface any turpentine, which by its continued contact 
may cause vesication. 

Turpentine Stupe. — Turpentine is often employed as a rubefacient by 
sprinkling spirits of turpentine over flannel which has been wrung ont 
of boiling water or by dipping hot flannel in warm spirits of turpentine ; 
prepared in either way, the stupe should be squeezed as dry as possible 
to remove the excess of turpentine before being applied to the surface of 
the body. A turpentine stupe may cause vesication if allowed to remain 
for too long a time in contact with the skin ; its application for from five 



CO UNTER-IRRITA TION. 7 9 

to ten minutes will usually produce the desired effect; it should be 
removed after this time, and can be reapplied if desired. If the patient 
complains of severe burning of the skin after the use of turpentine, the 
painful surface should be freely smeared with vaseline, \vhich will relieve 
this uncomfortable symptom. 

Chloroform. — A few drops of chloroform applied to the surface of 
the body by means of a piece of lint, muslin, or flannel, and covered by 
oiled silk or rubber tissue, will excite a rapid rubefacient effect. 

Mustard. — Ground mustard or mustard flour, prepared from either 
Sinapis alba or Sinapis nigra, is one of the most commonly-used sub- 
stances to produce rubefacient action. It is generally employed in the 
form of the mustard plaster or sinapism, which is prepared by mixing 
equal parts of mustard flour with wheat flour or flaxseed meal, and adding 
enough warm water to make a thick paste. This is spread upon a piece 
of old muslin, and the surface of the paste should be covered with some 
thin material, such as gauze, to prevent the paste from adhering to the 
skin. In making a mustard plaster for application to the tender skin 
of a child one part of mustard flour should be mixed with three parts of 
wheat flour or flaxseed meal. A mustard plaster or sinapism may be 
allowed to remain in contact with the skin for a period varying from 
fifteen to twenty minutes, the time being governed by the sensations of 
the patient ; if it is allowed to remain longer, it may cause vesication, 
which is to be avoided, as ulcers produced by mustard are very painful 
and extremely slow in healing. After removing a sinapism the irritated 
surface of the skin should be dressed with a piece of muslin or lint 
spread with vaseline, boric acid, or oxide-of-zinc ointment. 

Mustard Foot-bath. — To excite a rapid rubefacient action a mustard 
foot-bath is often employed : it is prepared by adding four tablespoonfuls 
of mustard flour to a bucket or foot-tub of water at a temperature of 
100° to 110° F. ; in this the patient is allowed to soak his feet for a few 
minutes. 

Mustard Papers. — Charta Sinapis, which can be obtained in the shops 
ready for use, are a convenient means of obtaining the rubefacient action 
of mustard. They are dipped in warm water, and, as they are generally 
very strong, it is well to place a piece of muslin between the plaster and 
the skin before applying it to the surface. 

Capsicum or Cayenne pepper is also employed as a rubefacient, but it 
is generally used in conjunction with spices, forming the well-known 
spiae planter, which is prepared by taking equal parts of ground ginger, 
cloves, cinnamon, and allspice, and adding to them one-fourth part of 
Cayenne pepper ; these are thoroughly mixed and enclosed in a flannel 
bag, and evenly distributed ; a few stitches should be passed through the 
bag at different points to prevent the powder from shifting its position ; 
before applying it one side of the bag should be wet with warm whiskey 
or alcohol. Capsioine plasters are also employed to obtain the rubefacient 
effect of Cayenne pepper. 

Aqua ammonice may also be employed for its rubefacient action. A 
piece of lint saturated with the stronger water of ammonia, placed upon 
the skin and covered with waxed paper, and allowed to remain for one 
or two minutes, will produce a marked rubefacient effect. 

Paquelin's Cautery. — By rapidly stroking the surface of the skin with 



80 MINOR SURGERY. 

the point or button of Paquelin's cautery at a black heat a marked 
counter-irritant action may be produced. 

Caution should be exercised in applying counter-irritation to patients 
who are comatose or under the influence of a narcotic, for here the sensa- 
tions of the patient cannot be used as a guide to their removal, and the 
too long-continued application when the vitality of the patient is impaired 
may result in serious consequences. 

Vesicants. — When it is desirable to make a more permanent counter- 
irritant effect than that produced by rubefacients, substances are employed 
which by their action on the skin cause an effusion of serum, or of serum 
and lymph, beneath the cuticle, thus giving rise to vesicles or blisters ; 
they are known as vesicants. 

The substance most commonly employed to produce vesication is 
cantharis, or Spanish fly, and the preparation commonly used is Ceratum 
Cantharidis, which is used in the form of the fly blister. This is prepared 
by spreading the cerate upon adhesive plaster, leaving a margin half an 
inch in width, which adheres to the skin and holds the plaster in posi- 
tion. The time usually required for a fly blister to produce vesication 
is from four to six hours ; it should then be removed and the surface 
should be covered with a flaxseed-meal poultice or with a warm-water 
dressing. When the blister or vesicle is well developed, it may be 
punctured at its most dependent part to allow the serum to escape, and 
it should be dressed with vaseline or boric ointment. If for any reason 
it is desired to keep up continued irritation after allowing the serum to 
escape, the cuticle should be cut away and the raw surface should be 
dressed with some stimulating material, such as the compound resin 
cerate. 

Cantharidal collodion may also be employed to produce vesication ; 
it is applied by painting several layers upon the skin with a brush over 
the part upon which the blister is to be produced. It is a convenient 
preparation to use when the patient would disturb the ordinary blister, 
as in the case of a child or an insane patient, or where the surface is so 
irregular that the ordinary blister cannot be well applied. The after- 
treatment of blisters produced by the use of the collodion is similar to 
that previously described. 

In the treatment of chronic inflammation it is often better to employ 
a number of small blisters at intervals than one large blister producing 
an extensive vesication of the surface. Care should be observed in using 
blisters upon the tender skins of children ; if employed, they should be 
allowed to remain in contact with the skin for a short time only. They 
are contraindicated in patients whose vitality is depressed by adynamic 
diseases and in aged persons. 

A complication which sometimes arises from the use of cantharidal 
preparations is strangury ,-Nh\ch is shown by frequent and painful micturi- 
tion, the urine often containing blood. This accident should be treated by 
the use of opium and belladonna by suppository, demulcent drinks, and 
warm sitz-baths, and by leeches to the perineum if the symptoms are 
very severe. 

To avoid the development of strangury small blisters should be 
employed, they should not be allowed to remain too long in contact 
with the surface, and cantharidal preparations should not be employed 



CO UNTEB-ISBITA TION. 



81 



Fig. 1 



in cases where renal or vesical irritation has existed or is present. 
Strangury may be also avoided by incorporating opium and camphor 
with the cantharidal cerate. 

Aqua animonicB fortior and chloroform may be employed to produce 
rapid vesication, a few drops being placed upon the surface of the body 
and covered by an inverted watch-glass for a few minutes, or lint satu- 
rated with aqua ammonia or chloroform may be placed upon the skin 
and covered with waxed paper or oiled silk. Either of these agents 
applied in this manner and allowed to remain in contact with the skin 
for fifteen minutes will produce marked vesication. The blisters result- 
ing from these agents are painful, and they are only to be used where 
rapid result is desired. 

Nitrate of silver, in a strong solution or in the form of the solid stick, 
may be applied to the surface of the skin to produce a counter-irritant 
effect. Nitrate of silver, applied by drawing the moist stick across the 
skin of the scrotum at a number of points, was formerly a popular treat- 
ment for acute epididymitis. 

Acupuncture. — In this method of counter-irritation needles are 
thrust deeply into the subcutaneous tissues. The needles employed 
for this purpose should be of steel, from two to four, 
inches in length, strong, highly polished, and sharp- 
pointed, and should have round metallic heads or be 
fixed in handles (Fig. 89). They should be rendered 
perfectly aseptic by being allowed to remain for a few 
minutes in boiling water or in a carbolized solution. In 
performing the operation of acupuncture localities con- 
taining important organs, large blood-vessels, nerves, 
the joints, and viscera should be avoided. When intro- 
duced, the needles should be passed through the skin 
with a rotary motion, the skin being rendered tense be- 
tween the thumb and fingers, and thrust into the deep- 
seated structures. They are allowed to remain in posi- 
tion for a few minutes, and are then withdrawn, the 
skin being supported by the thumb and fingers. Acu- 
puncture has been found of service in deep-seated neur- 
algias, obstinate rheumatic affections, and sciatica. 

Issues. — Issues are ulcers made intentionally by the 
application of caustics, the moxa, or the knife. Thej^ 
are not much employed at the present time, but were 
formerly a popular means of causing long-continued counter-irritation. 
In making an issue a region was selected where the subcutaneous cellular 
tissue was abundant and which was free from large blood-vessels and 
nerves, and not near the joints. The plan usually adopted was to apply 
over the surface of the skin a piece of adhesive plaster perforated in the 
centre. A small piece of caustic potash or Vienna caustic, mixed with 
water to make it a paste, was placed in the hole in the adhesive plaster 
and held in position by a strip of adhesive plaster. In one or two hours 
the plaster should be removed, and the parts should be washed with 
dilute acid to prevent further action of the caustic ; a poultice of flax- 
seed should next be applied to hasten the separation of the slough. The 
ulcer remaining after the removal of the slough was kept from healing 

Vol. II.— 6 



Acupuncture needles. 



82 



MINOR SURGERY. 



by introducing into it a small wooden ball known as an issue pea, 
or a glass bead or pebble, held in place by a compress and 
^^'^- adhesive strip. 

^^ The knife was also employed to establish an issue, a cru- 

cial incision being made between the skin and cellular tis- 
sues into the deep tissues ; the objection to the use of the 
knife in forming an issue was the difficulty in preventing 
the wound from healing. 

The moxa was formerly used to make an issue : it consisted 
of a small mass of some combustible material, such as punk, 
cotton, or lint, rolled into pyramidal shape, which was placed 
upon the surface of the body and ignited so as to produce an 
eschar upon the skin. To facilitate the application of the 
moxa an instrument called the porte-moxa was employed 
(Fig. 90). The treatment of the eschar resulting from the 
moxa is the same as that resulting from the use of caustic 



Porte-moxa. 



potash. 



The Seton. — A seton is a subcutaneous sinus or an issue with two 
openings upon the surface, which is prevented from healing by the 

Fig. 91. 




Seton needle. 



introduction of a foreign body. It is established by introducing a few 
strands of silk, a narrow strip of linen, or a rubber ligature by means 
of a seton needle (Fig. 91). The seton needle should be passed deeply 



Fig. 92. 




Method of forming a seton 

into the superficial fascia, care being taken to avoid important veins and 
nerves. 

A seton may also be established by pincliing up a fold of skin and 
transfixing its base with a narrow, sharp-pointed bistoury (Fig. 92), 
and passing through the wound thus made an eyed probe armed with a 



CO UNTER-IBRITA TION. 



83 



few strands of silk, a strip of muslin, or an elastic ligature ; the probe 
is then removed and the ends are loosely tied together. At each change 
of the dressing the strip or seton should be made to change its position 
by drawing it forward or backward, and it may be smeared with some 
stimulating ointment, which can thus be brought in contact with the 
granulating surface of the sinus. 

Actual Cautery. — This method of counter-irritation is accomplished 
by bringing in contact with the skin some metallic substance brought to 
a red heat. This constitutes one of the most powerful means of coun- 
ter-irritation and revulsion ; it is rapid in its action, and is not more 
painful than some of the slower methods. The cauteries generally em- 
ployed are made of iron, fixed in handles of wood or other non-conduct- 
ing material, and have their extremities fashioned in a variety of shapes 
(Fig. 93). The cautery-irons are heated by placing their extremities 

Fig. 93. 




Cautery-irona. 

in an ordinary fire or by holding them in the flame of a spirit-lamp 
until they are heated to the desired point, either to a bright or dull-red 
heat. They are then applied to the surface of the skin at one point, or 
drawn over the skin in lines either parallel to or crossing one another. 
The intense burning which follows the use of the cautery may be allayed 
by placing upon the cautery-marks compresses wrung out in ice-water or 
saturated with equal parts of lime-water and sweet oil. 

When the ordinary cautery-irons are not at hand, a steel knitting- 
needle or iron poker heated in the flame of a spirit-lamp or in a fire may 
be employed with equally satisfactory results. Where the cautery-iron 
is held in contact with the surface for some time to make a deep burn, 
the pain of its application may be allayed by placing a mixture of salt 
and cracked ice upon the spot to be cauterized for a few minutes imme- 
diately before its application. The cautery-iron should not be placed over 
the skin covering salient parts of the skeleton or over important organs. 

Actual cautery, in addition to its use in producing counter-irritation 
and revulsion, is often employed to control hemorrhage and to destroy 
morbid growths. 

Paquelin's Thermo-cautery. — The apparatus of Paquelin consti- 
tutes a very convenient and efficient means of using a thermo-cautery : 
it utilizes the property of heated platinum-sponge to become incandes- 
cent when exposed to the action of the vapor of benzole or rhigolene 
(Fig. 94). The cautery is prepared for use by attaching the gum tube 
to the receiver containing benzole, and heating the platinum knife or 



84 



MINOR SURGERY. 



button, which is attached to the benzole receiver by a rubber tube, in 
the flame of an alcohol lamp for a few minutes, and then passing the 
vapor of benzole through the platinum-sponge, which is enclosed in 



Fig. 94. 




Paquelin's cautery. 

the knife or button, by compressing the rubber bulb. The cautery points 
may be brought either to a high degree of heat, or only to a dull-red 
heat. This form of cautery may be employed for the same purposes as 
that previously mentioned ; its great advantage consists in the ease with 
which it can be prepared for use. In this form of cautery the knife, 
heated to a dull-red heat, will be found of great service in operating 
upon vascular tumors, Avhere the use of an ordinary knife would be 
accompanied by profuse or even dangerous hemorrhage. Wounds made 
by the actual cautery are aseptic wounds, and when dusted with iodoform 
will usually heal promptly under the scab without suppuration. 

Bloodletting. 

Bloodletting is resorted to to obtain both the local and general effects 
following the withdrawal of blood from the circulation. Local depletion 
is accomplished by means of some one of the following procedures : scar- 
ification, puncturation, cupping, and leeching, and general depletion is 
effected by means of venesection or arteriotomy. 

Scarification. — Scarification is accomplished by making small and 
not too deep incisions into an inflamed or congested part Avith a sharp- 
pointed bistoury ; the incisions should be in parallel lines and should be 
made to correspond to the long axis of the part, and care should be taken 
in making them to avoid wounding superficial nerves and veins. In- 
cisions thus made relieve tension by allowing blood and serum to escape 
from the engorged_ capillaries of the infiltrated tissue of the part. Warm 
fomentations applied over the incisions will increase and keep up the 
flow of blood and serum. Scarification is employed with advantage in 



BLOODLETTING. 



85 



inflammatory conditions of the skin and subcutaneous cellular tissue, and 
in acute inflammatory swelling or oedema of the mucous membrane — for 
instance, of the conjunctiva ; and in acute inflammation of the tonsils, 
tongue, and epiglottis it is an especially valuable procedure. 

Deep Incisions. — A modification of scarification known as deep in- 
cisions is practised by making deep incisions into the inflamed or infil- 
trated tissues, care being taken to avoid the wounding of important vessels 
and nerves. This procedure is practised in urinary infiltration to estab- 
lish drainage and relieve the tissues of the contained urine and to prevent 
sloughing ; in threatened gangrene and phlegmonous erysipelas the same 
procedure is adopted to relieve tension by permitting the escape of blood and 
serum, and its employment is often followed by most satisfactory results. 

Puncturation. — Puncturation consists in making punctures, which 
should not extend deeper than the subcutaneous tissue, into inflamed 
tissues with the point of a sharp-pointed bistoury : it is an operation 
similar in character to that just described, its object being to relieve ten- 
sion and bring about depletion. It is employed in cases similar to those 
in which scarification is indicated, and is resorted to in cases of diffuse 
areolar inflammation or erysipelas. 

Cupping. — Cupping is a convenient method of accomplishing local 
depletion by inviting the blood from the deeper parts to the surface of 
the skin. Cupping is accomplished by the use of wet or dry cups. When 
dry cups are used, no blood is abstracted and the derivative action only 
is obtained ; when wet cups are employed, there is an actual abstraction 
of blood or local depletion, as well as the derivative action. 

Dry Cupping. — Dry cupping as ordinarily applied consists in the use 
of small cup-shaped glasses which have a valve and stopcock at their 
summit : these are placed upon the skin and an air-pump is attached, 
and as the air is exhausted in the cup the congested integument is seen 
to bulge into the cavity of the cup (Fig. 95). When the exhaustion 
is complete the stopcock is turned and the air-pump is 
removed, the cup being allowed to remain in position 
for a few minutes, and it is then removed by turning the 
stopcock and allowing the air again to enter the cup. 
This procedure is repeated until a sufficient number of 
cups have been applied. 

In cases of emergency, when the ordinary cupping- 
glasses and air-pump cannot be obtained, a very satisfac- 
tory substitute may be obtained by taking an ordinary 
glass and burning in it a little roll of paper or a small 
piece of lint or paper wet with alcohol, and before the 
flame is extinguished rapidly inverting it upon the skin, 
or the air may be exhausted by the introduction into the 
cup, for a moment or two, of the flame of a spirit-lamp. 
Applied in this manner, cups will draw as well as when 
the more complicated apparatus is used, and when they 
are removed it is only necessary to press the finger on the 
skin close to the edge of the cup until air enters, when it 
will fall off-. 

Although dry cups do not remove blood, there is often 
an escape of blood from the capillaries into the skin and cellular tissue, 



Fig. 95. 



1 



Cupping-glass and 
air-pump. 



86 



MINOR SURGERY. 



Pig. 96. 




Scarificator. 



as is evidenced by the ecchymosis which frequently remains at the seat 
of the cup-marks for some days. Dry cups, as previously stated, are 
employed for their derivative action in cases in which depletion is not 
indicated. 

Wet Cupping. — "Wet cups are resorted to when the abstraction of the 
blood as well as the derivative action is desired, and here it is necessary 
to have a scarificator as well as the cups and air-pump. 

Before applying wet cups the skin should be carefully washed with a 
carbolic solution, and the scarificator (Fig. 96) should also be dipped in 
the same solution. A cup is first applied to pro- 
duce superficial congestion of the skin ; this is 
removed and the scarificator is applied, and the 
skin is cut by springing the blades, and the cups 
are immediately applied and exhausted ; and they 
are kept in place as long as blood continues to flow. 
When the vacuum is exhausted and blood ceases 
to flow, they should be removed and emptied, and 
can be reapplied if it is desirable to remove more 
blood. A sharp-pointed bistoury which has been 
sterilized may be employed to make a few incisions 
into the skin instead of the scarificator, and the 
improvised cups may be employed if the ordinary 
cupping apparatus cannot be obtained. After the removal of wet cups 
the skin should be washed carefully with. bichloride or carbolic solution, 
and an antiseptic dressing should be applied and held in place by a roller 
bandage. 

Leeching. — Two varieties of leeches are used in the abstraction of 
blood by leeching — the Ameriean leech, which draws about a teaspoonful 
of blood, and the Swedish leech, which draws three or four teaspoonfuls. 
Before applying leeches the skin should be carefully washed, and the 
leech should be placed upon the part from which the blood is to be drawn, 
and confined to this place by inverting a tumbler or glass jar over him ; 
if he does not bite or take hold, a little milk or blood should be smeared 
upon the surface, which ^vill generally secure the desired result. As soon 
as the leech has ceased to draw blood he is apt to let go his hold and fall 
off; if, however, it is desired to remove leeches, they may be made to let 
go their hold by sprinkling them with a little salt. After the removal 
of leeches, bleeding from the bites may be encouraged by the application 
of warm fomentations. Leech-bites should be washed with a bichloride 
or carbolic solution, and a compress of bichloride or iodoform gauze 
should be placed over them and secured by a bandage. It occasionally 
happens that free bleeding continues from the leech-bite after the removal 
of the leech ; in this event, if a compress does not control the hemor- 
rhage, the bleeding points should be touched with a stick of nitrate of 
silver or with the point of a steel knitting-needle heated to a dull-red 
heat; and if this fails to control the bleeding a delicate hare-lip pin 
should be passed through the skin under the bite, and a twisted suture 
should be thrown around this ; the wound should then be washed and 
dressed as previously described. 

In applying leeches in or near mucous cavities care should be taken 
to see that they do not escape into the cavities and pass out of reach. 



BLOOD-LETTING. 



87 



Fig. 97. 



Leeches should not be employed directly over inflamed tissues, but 
should be applied to the parts surrounding them ; they should 
not be allowed to take hold directly over a superficial 
artery, vein, or nerve ; and should never be applied to 
a part where there is delicate skin and a large amount 
of loose cellular tissue, as in the eyelid or scrotum, as 
unsightly ecchymoses will result which will persist for 
some time. Leeches should not be used a second time. 

Mechanical Leech. — A mechanical leech consists of 
a scarificator, cup, and exhausting syringe or air-pump 
(Fig. 97). In using this apparatus, after the scarificator 
has been used the piston of the exhausting instrument 
should be drawn out slowly, which secures a better flow 
of blood than if a sudden vacuum is made. 

The mechanical leech may be employed when the 
natural leech cannot be obtained, but possesses no advan- 
tage over the latter, and is apt to get out of order if not 
in constant use. 

Venesection. — Venesection consists in the division or 
opening of a vein, and is the ordinary operation by 
which general depletion or bleeding is accomplished. 
Venesection at the bend of the elbow is the operation 
which is now usually resorted to for general bloodletting ; 
the vein selected is the median cephalic, which is farther from the line 
of the brachial artery than the median basilic vein (Fig. 98). 



Fig. 98. 




Venesection (Heath). 

To perform venesection the surgeon requires a bistoury or lancet — 
the spring lancet was formerly much used, but it is not employed at the 
present time — several bandages, a small antiseptic dressing, and a basin 
to receive the blood. The patient's arm should be carefully cleansed, 
washed with a bichloride solution, and a few turns of a roller bandage 
should be placed around the middle of the arm, being applied tightly 
enough to obstruct the venous circulation and make the veins below be- 
come prominent, but not to obstruct the arterial circulation. The patient 
at the same time should be instructed to grasp a stick or a roller bandage 
and work his finger upon it. The surgeon should next assure himself 
that there is no abnormal artery beneath the skin, and having selected the 
vein, the median cephalic by preference, he steadies the vein with his 
thumb and passes the point of the bistoury or lancet beneath and cuts 
quickly outward, making a free skin opening. The blood usually 



88 MINOR SURGERY. 

escapes freely, and the amount withdrawn is regulated by the condition 
of the pulse and appearance of the patient. For this reason it is better 
to have the patient sitting up or semi-reclining when venesection is per- 
formed, as the surgeon can judge better as to the constitutional effects 
of the loss of blood while the patient is in this position. When a suf- 
ficient quantity of blood has been removed, the thumb is placed over 
the wounded vein and the bandage is removed from the arm above. 
The wound is next washed with a bichloride solution, and a compress 
of antiseptic gauze is applied over it and held in position by a bandage, 
which should be so applied as to envelop the arm from the fingers to 
the axilla. The dressing need not be disturbed for five or six days, at 
which time the wound is usually found to be healed. 

The brachial artery has been wounded in performing venesection at 
the bend of the elbow, but if care is taken this accident should not 
occur. 

Venesection has been practised on the external jugular vein when, 
from the excess of fat or in the case of children, the veins at the bend 
of the elbow cannot be easily found. The vein is rendered prominent 
by placing the thumb or a pad over the vein at the outer edge of the 
sterno-cleido-mastoid muscle just above the clavicle. The vein is next 
opened over this muscle by an incision parallel to its fibres. After 
a sufficient quantity of blood has escaped the wound is washed with 
an antiseptic solution, and closed by a compress of antiseptic gauze held 
in position by a bandage carried around the neck. 

The internal saphena vein has also been selected for venesection, and 
here care should be taken not to wound the accompanying nerve, which 
lies directly behind the vein. 

Arteriotomy. — This operation is now scarcely ever performed, but 
if done the vessel generally selected is the anterior branch of the tem- 
poral artery, which is opened by a transverse incision with a bistoury. 
After a sufficient quantity of blood has escaped the wound is inspected, 
and if the vessel is not completely divided its division is completed, and 
the ends of the vessel secured with catgut ligatures and the wound 
douched with an antiseptic solution. A gauze compress should be 
applied and held in position by a firmly-applied bandage. 

Transfusion of Blood. 

Transfusion of blood may be employed to introduce a certain quan- 
tity of blood into the circulation of a patient who has suffered from 
profuse hemorrhage. There are two methods by which transfusion may 
be effected : the direct, by which the blood is conveyed directly and 
without exposure to the air from the blood-vessel of one person to that 
of another, and the indirect, in which the blood is drawn from the vein 
of one person and is then injected into the vein of another, being first 
deprived of its fibrin before being injected. 

Direct Transfusion of Blood. — This is best accomplished by using 
Aveling's apparatus, which consists of a rubber tube about eighteen 
inches in length, with a small rubber bulb in the centre, having metallic 
extremities provided with stopcocks, and two bevel-pointed metallic 
canulse, to be used to connect the tube with the blood-vessels. In per- 



TRANSFUSION OP BLOOD. 



89 



forming the operation of direct transfusion the bulb and tube are first 
placed in a shallow basin containing warm normal saline solution (0.7 
per cent.), and the bulb and tube are filled with this solution to dis- 
place any air which they contain. The person supplying the blood 
places his arm near the arm of the patient, and the operator exposes 
a prominent vein of the patient's arm at the bend of the elbow and 
opens it, and inserts into it one of the canulse filled with saline solution, 
with the point directed toward the body, and at the same time an 
assistant should introduce the other canula into a vein at the bend of 
the elbow of the person who supplies the blood. The canulse are held 
in position by assistants, and the tube is quickly connected with them, 
the stopcock being closed before it is taken out of the saline solution, 
to prevent the entrance of air ; then upon opening the stopcocks 
a direct connection is established between the circulation of the patient 
and that of the person who supplies the blood (Fig. 99). 

Fig. 99. 




Apparatus for the direct transfusion of blood. 

The introduction of the contents of the bulb into the vein of the patient 
is efi^ected by the operator slowly compressing the bulb with one hand, while 
he keeps the tube closed on the side of the donor with the finger and 
thumb of the other hand. By relaxing the pressure on the donor's side 
of the bulb, and closing it on the patient's side, blood will flow from the 
donor into the bulb as it slowly expands, and when filled the communi- 
cation with the patient's circulation is again made, and the manipulation 
is repeated until a sufficient quantity of blood has been introduced, as 
indicated by the condition of the patient's pulse. The quantity of 
blood or saline solution introduced can be calculated by remembering 
that at each emptying of the bulb two drachms of fluid are introduced 
into the circulation. When a sufficient quantity has been introduced 
the canulse are removed and the wounds are dressed as ordinary venesec- 
tion-wounds. 

Indirect Transfusion of Blood. — Indirect transfusion of blood is 
accomplished by withdrawing from the vein of the donor by venesection 
about ten ounces of blood, which is received into a clean glass or porce- 



90 



MINOR SURGERY. 



lain vessel which is placed in water at a temperature of 110° F. The 
blood thus kept warm is next defibrinated by whipping it with a bundle 
of broom straws or a wire brush, and after being filtered through a fine 
linen cloth or wire strainer it is injected by means of an ordinary 
syringe attached to a canula which has been previously inserted into the 
vein of the patient, care being taken that no air is introduced with the 
blood. When a sufficient quantity of blood has been introduced the 
canula is removed and the wound is dressed in the usual manner. The 
success of this operation depends largely upon the expedition with which 
it is performed ; to prevent coagulation of the blood, not more than two 
minutes should be allowed to intervene between the reception of the 
blood in the syringe and its introduction into the patient's vein. 

The best form of apparatus for indirect transfusion of blood is that 
devised by Dr. J. G. Allen and modified by the late Dr. C. T. Hunter 
(Fig. 100). 

Fig. 100. 




Apparatus for indirect transfusion of blood. 

Arterial Transfusion. — This procedure, which consists in injecting 
defibrinated venous blood into an artery, is occasionally practised. An 
artery, usually the radial at the wrist or the posterior tibial behind the 
inner malleolus, is exposed and secured by a ligature ; it is then opened 
on the distal side of the ligature, and the point of a canula or the nozzle 
of a syringe is introduced directed toward the distal extremity of the 
limb, and blood which has been previously defibrinated is slowly injected. 
When a sufficient quantity has been introduced the canula is removed, the 
division of the artery is completed, its extremities are secured by liga- 
tures, and the wound is closed and dressed. 

Auto-transfusion. — Auto-transfusion is a procedure which is recom- 
mended in cases of excessive hemorrhage to support a moribund patient 
until other means of resuscitation can be adopted. It consists in the 
application of rubber bandages or of muslin bandages to the extrem- 
ities for the purpose of forcing the blood toward the vascular and 
nervous centres. 

Intra- venous Injection of Saline Solution. — The injection into the 
veins of normal salt solution has been proved by experiment and by 
clinical experience to be more efficacious in supplying volume to and 
restoring a rapidly-failing circulation than human blood, and, as the 



INTBA-VENOUS INJECTION. 91 

former can be obtained with much more ease than blood, its use has 
largely superseded the latter. The saline solution which is found most 
satisfactory to employ for this purpose is known as normal saline solu- 
tion (0.7 per cent.), prepared by adding a drachm of salt to one pint of 
boiled water. The solution should be prepared with water which has 
been sterilized by boiling, and should be at a temperature of 100° F. 
when used. A vein of the patient, at the elbow, should be exposed, and 
should have placed under it, about half an inch apart, two catgut liga- 
tures ; the distal ligature is then tied and an opening is made into the vein 
between the ligatures. A canula is next inserted into the opening in the 
vein, and is secured in position by tying the proximal ligature. The 
canula is first filled with the saline solution, and is then connected with 
a funnel by means of a rubber tube (Fig. 101), which is filled with 

Fig. 101. 




Funnel and tube for intra-venous injection. 



saline solution to displace the air, and upon raising the funnel above the 
part the solution enters the vein ; care should be taken to see that the 
funnel is kept well filled with solution until a sufficient quantity has 
been introduced. The quantity introduced is regulated by the condition 
of the patient's pulse. 

Saline solution may also be introduced by means of a syringe when 
the apparatus described cannot be obtained. Large injections of normal 
salt solution may be introduced into the cellular tissue by means of 
hypodermic injections, or the needle may be introduced into the cellular 
tissue and connected by a piece of rubber tubing, with an irrigator con- 
taining normal salt solution held above the part, and the solution grad- 
ually finds its way into the subcutaneous cellular tissue. A large quan- 
tity of fluid may be introduced in this way. 

Intra-venous Injection of Milk. — The intra-venous injection of 
cow's or goat's milk has also been employed as a substitute for transfu- 
sion of blood in patients who have suffered from excessive hemorrhage 
or from diseases which greatly deteriorate the quality of the blood. In 
making one of these injections the same apparatus is employed and the 



92 MINOR SVRGEBY. 

steps of procedure are similar to those used in making intra-venous 
injection of saline solution. The milk to be injected should be fresh, 
and should be warmed and strained through a fine wire or linen strainer. 
This injection has been employed in cases of pernicious anaemia, typhoid 
fever, and carbolic-acid poisoning with apparently beneficial results. 

Artificial Eespieation. 

Artificial respiration is resorted to in cases of threatened death from 
apnoea consequent upon drowning, profound ansesthetization, or the 
inhalation of irrespirable gases, or where from any cause there is inter- 
ference with the function of breathing. Before resorting to artificial 
respiration care should be taken that the mouth and air-passages are free 
from any substance which would obstruct the entrance of air into the 
lungs, such as mucus, foreign bodies, or liquids, and also that all tight 
clothing interfering with the free expansion of the chest-walls is removed 
from the chest. Where apncea is due to a foreign body in the larynx or 
trachea tracheotomy should be performed before artificial respiration is 
attempted. 

When artificial respiration is resorted to, it should be persevered 
with for some time, even when no apparent spontaneous respiratory 
movements are excited ; for resuscitation has been accomplished in seem- 
ingly hopeless cases by patient perseverance with the manipulations. 
When the first natural respiratory movement is detected the operator 
should not cease making artificial respiration, but should continue these 
movements in such a way as to coincide with the spontaneous inspiratory 
and expiratory movements until the breathing has assumed its regular 
character. 

The temperature of the body should also be restored by frictions 
to the surface of the body by the hands or by rough towels, and hot- 
water bottles and warm coverings should be applied with the same 
object. 

Mouth-to-mouth Inflation. — This method of artificial respiration 
has been resorted to in cases of great emergency, especially in very 
young children. The operator draws the tongue forward, closes the 
nostrils, applies his mouth directly to the mouth of the patient, and by 
a deep expiratory eifort endeavors to force air into the chest ; when 
this is accomplished the air can be expelled from the lungs by pressure 
upon the walls of the chest, and the procedure should be repeated about 
twelve or sixteen times in a minute. The same object may be accom- 
plished by passing a flexible catheter into the trachea through the 
mouth, or by passing an intubation-tube, to the upper part of which a 
rubber tube is attached, into the larynx ; this can be passed with the 
fingers without difficulty, and the lungs can then be inflated by the ope- 
rator blowing into the mouth or tube or by attaching to it a pair of 
bellows. 

Dr. Eichardson of London has devised a pocket-bellows for inflation 
of the lungs through the nostrils (Fig. 102). The apparatus consists of 
two elastic bulbs to which two rubber tubes are attached, which termi- 
nate in a single tube. In using this bellows the terminal tube is intro- 
duced into one nostril, the other nostril and mouth being closed ; air is 



ARTIFICIAL BESPIRATION. 



93 



forced into the lungs by compressing one bulb, and withdrawn by com- 
pressing the other. 

Fig. 102. 




Ricliardson's bellows for artificial respiration. 

Howard's Direct Method of Artificial Respiration. — This method 
of artificial respiration is the one adopted by the United States Life- 
saving Service, and is considered the most efficacious, and, although the 
rules given are for the resuscitation of cases of apparent drowning, the 
same procedure may be adopted in cases of apnoea arising from other 
causes. 

The rules of Howard's method of artificial respiration are as follows -. 

Rule I. — " To expel air from the stomach and lungs, strip the patient 
to the waist, and if the jaws are clenched separate them and keep them 
apart by placing between them a piece of cork or a small piece of wood. 
Place the patient's face downward, the pit of the stomach being raised 
above the level of the mouth by a large roll of clothing placed beneath 
it (Fig. 103). Throw your weight forcibly two or three times upon the 

Fig. 103. 




First manipulation in Howard's method. 

patient's back over the roll of clothing, so as to press all fluids in the 
stomach out of the mouth." 

The first rule applies only to cases of drowning, and in using How- 
ard's method in apncea from other causes it is to be omitted. 

Rule II.—" To perform artificial respiration, quicldy turn the patient 
upon his back, placing the roll of clothing beneath it, so as to make the 
breast-bone the highest point of the body. Kneel beside or astride of 
the patient's hips. Grasp the front part of the chest on either side of 



94 



MINOR SURGERY. 



the pit of the stomach, resting the fingers along the spaces between the 
short ribs. Brace your elbows against your sides, and, steadily grasping 
and pressing forward and upward, throw your whole weight upon the 
chest, gradually increasing the pressure while you count one, two, three 
(Fig. 104). Then suddenly let go with a final push, which brings you 
back to your first position. Rest erect upon your knees while you count 

Fig. 104. 




Direct method of artificial respiration. 



one, two ; then make pressure again as before, repeating the entire 
motions at first about four or five times a minute, gradually increasing 
them to about ten or twelve times. Use the same regularity as in blow- 
ing bellows and as seen in the natural breathing, which you are imitat- 
ing. If another person is present, let him with one hand, by means of 
a dry piece of linen, hold the tip of the tongue out of one corner of the 
mouth, and with the other hand grasp both wrists and pin them to the 
ground above the patient's head." 

This method may be employed in cases of stillbirth or in young 
children, the operator holding the chest of the child in his left hand and 
compressing it with the right hand. 

Sylvester's Method of Artificial Respiration. — In employing this 
method of artificial respiration the patient should be placed upon his 
back on a firm, flat surface ; a cushion of clothing is placed under the 
shoulders, and the head should be dropped lower than the body by tilt- 
ing the surface upon which he is laid. The mouth being cleared of 
mucus or foreign substances, the tongue is drawn forward and secured 
to the chin by a piece of tape tied around it and the lower jaw, or may 
be pulled out of the mouth and held by an assistant. The operator, 
standing at the patient's head, grasps the arms at the elbows and carries 
them first outward and then upward until the hands are brought above 
the head ; this manipulation represents inspiration (Fig. 105) : they 
should be kept in this position for two seconds, after which they are 
brought slowly back to the sides of the thorax and pressed against it for 
two seconds ; this manipulation represents expiration (Fig. 106). These 
movements are repeated fifteen times in a minute until the breathing is 
restored or until it is evident that the case is a hopeless one. 

Marshall Hall's Ready Method of Artificial Respiration. — In 



ARTIFICIAL RESPIRATION. 95 

practising this method of artificial respiration the mouth should first be 
freed from mucus or foreign bodies, and the patient is turned upon his 
face with one wrist under his forehead, and a roll of clothing is placed 

Fig. 106. 




Sylvester's method : inspiration (Esmarch). 



beneath his chest. By turning the body briskly on the side and a little 
beyond, and then on the face, alternately, respiration is imitated. As 
the body is brought into the prone position, compression is made upon 



Fig. 106. 




Sylvester's method ; expiration (Esmarch). 

the posterior aspect of the chest. These manipulations should be made 
fifteen times in a minute. 

Laborde's Method of Artificial Respiration by Rhythmical Trac- 
tion upon the Tongue. — Laborde states that systematic and rhythmic 
traction of the tongue is a powerful means of restoring the respiratory 
reflex, and consequently the function of respiration. The procedure is 
accomplished as follows : The body of the tongue is seized between the 



96 MINOR SURGERY. 

thumb and finger, and traction is made upon it, with alternate relaxation, 
fifteen or twenty times a minute, imitating the function of respiration, 
taking care to draw well on the tongue. When a certain amount of 
resistance is felt, it is a sign that the respiratory function is being 
restored ; noisy respiration first occurs, termed by Laborde " hoquet 
inspirateur" (inspiratory hiccough). Tongue forceps or dressing or 
haemostatic forceps may be used in the place of the fingers to grasp the 
tongue. It is important to continue the traction with persistence for 
half an hour to an hour and a half 

The procedure is said to have been employed with success in cases 
of drowning, toxic asphyxia, chloroform asphyxia, tetanus, and asphyxia 
after electric shock. 

In using any of these methods of artificial respiration the operator 
should persevere with them for from thirty minutes to, an hour before 
abandoning the case as a hopeless one. 

Forced Respiration. — This is a method of artificial respiration in 
which air is forcibly passed into the lungs through the mouth and larynx. 
This procedure has been strongly advocated by Dr. George E. Fell, who 
has devised an apparatus by which it can be satisfactorily accomplished. 
The apparatus of Fell, which has been used in a number of cases with 
good results, consists of a tracheotomy-tube, a tube connected with the 
air-control valve which is attached to an air-warming apparatus, which 
in turn is connected with a bellows by another tube. By means of this 
apparatus air is forced into the lungs, and allowed to escape when the 
lungs have been expanded by the elasticity of the lung-tissue and the 
chest- walls. 

Prof. H. C. Wood has also employed forced respiration in the resusci- 
tation of animals with an apparatus somewhat similar to that devised by 
Dr. Fell, with good results. Wood's apparatus consists of a pair of 
bellows, a few feet of rubber tubing, which are attached either to a face- 
mask of rubber or to an intubation-tube ; the mask or intubation-tube is 
attached to one end of the rubber tube and the bellows to the other end 
of the tube. The mask is applied over the mouth, or, if this is not used, 
the intubation-tube is introduced into the larynx, and air is forced into 
the lungs by working the bellows. He also advises that in the tubing a 
double metal tube be introduced, with openings placed so that their size 
can be so regulated by turning the outer tube that the operator can allow 
any excess of air thrown by the bellows to escape. Forced respiration 
will prove of value in cases of narcotic poisoning and other accidents in 
which death is produced by paralysis of the respiratory centres. Dr. 
Fell has reported a number of cases of narcotic poisoning in which he 
has used his apparatus with the most satisfactory results. 

Aspiration. 

This procedure is adopted to remove fluid from a closed cavity with- 
out the admission of air, and the instrument which is employed to 
accomplish this object is known as an "aspirator." Fluids niav be 
removed simply by having an empty soft rubber bag or bladder attached 
to a sharp-pointed canula, which is introduced into a closed cavity, and 
the fluid by atmospheric pressure escapes and distends the bag. 



ASPIBATION. 



97 



The two forms of aspirator most commonly employed are those of 
Dieulafoy and Potain. 

Potain's aspirator consists of a glass bottle, into the stopper of which 
is introduced a metallic tube, which is connected with two rubber tubes, 
one of which is connected with an exhausting-pump, and the other with 
a delicate canula carrying a fine trocar ; the apparatus is provided with 
stopcocks to prevent the admission of air (Fig. 107). In using this 

Fia. 107. 




Potain's aspirator. 



aspirator the bottle is exhausted of air by using the air-pump ; the canula 
enclosing the trocar is next pushed through the tissues into the cavity 
containing the fluid to be removed ; the trocar is next removed, and 
upon opening the stopcock the fluid is forced out of the cavity by 
atmospheric pressure and passes into the bottle or receiver. if the 
fluid contains masses of lymph or clots which block the canula, inter- 
rupting the flow of fluid, a stylet should be passed through the canula to 
free it of the obstruction. 

To diminish the pain produced in introducing the trocar and canula 
the skin at the point to be punctured may be rendered less sensitive by 
holding in contact with it for a few minutes a piece of ice wrapped in a 
towel or a towel containing broken ice and salt. Care should be taken 
to see that the trocar and canula are perfectly clean : to accomplish this 
they should be carefully washed and placed in boiling water or a 5 per 
cent, carbolic solution before being used. After removing the trocar 
and canula the small puncture should be dressed with a compress of 
bichloride or iodoform gauze held in place by a bandage or adhesive 
straps. 

The aspirator is frequently employed in cases of hydrothorax, 
empyema, and ascites, to evacuate the contents of cold abscesses in 
diseases of the hip and spine, and to remove the contents of a distended 
bladder until a more radical operation can be performed. It is also a 
valuable instrument for diagnostic purposes, being frequently used to 
ascertain the character of the contents of deep-seated collections of 
fluid. 

Vol. II.— 7 



98 MINOR SUROEBY. 

The Stomach-tube. 

This consists of a flexible tube about twenty-eight inches in length 
and three-eighths of an inch in diameter, which is introduced while the 
patient is in the sitting posture, the head being thrown backward so as 
to bring the mouth and gullet as nearly as possible in the same line. 
The tube being warmed and oiled, the surgeon, standing in front of the 
patient, passes it directly back to the pharynx, at the same time intro- 
ducing the index iinger of the left hand to guide its point over the 
epiglottis : it is then passed gently downward into the stomach. If any 
obstruction is met with in its passage, it should be withdrawn a little 
way and then pushed gently downward : all manipulations should be 
made without much force to prevent the perforation of the wall of the 
oesophagus. 

The introduction of the stomach-tube may be required for the evacua- 
tion of poisons from the stomach or to wash out the cavity of this viscus, 
and it may also be used to introduce liquid nourishment into the stomach 
of patients who are unable or unwilling to swallow food. In the 
recently-introduced methods of treating disorders of the stomach and 
intestines by washing them out, lavage, the introduction of a stomach- 
tube is required ; the tube here employed is from twenty-four to thirty 
inches in length (Fig. 108) and the fluid is introduced by means of a 

Fig. 108. 




funnel attached to its free extremity, or the tube may be attached to a 
stomach-pump. In introducing liquid nourishment a syringe or funnel 
is fitted to the exposed end of the tube which has been passed into the 
stomach ; the syringe or funnel having been filled with milk, beef tea, or 
broth, the contents are injected gently or allowed to run slowly into the 
stomach. In cases of poisoning, where it is desirable to withdraw the 
contents of the stomach and to wash out the organ, a stomach-tube and 
syringe may be employed ; several syringefuls of warm water are first 
thrown into the stomach and then withdrawn by suction, and in cases 
of emergency this simple apparatus may be employed, but the use of the 
stomach-pump will be found more satisfactory. 

The Stomach-pump. 

This consists of a brass syringe, the nozzle of which is connected with 
two tubes, one at the end, the other at the side. The passage through 
the nozzle is regulated by a valve controlled by a lever. The nozzle of 
the pump is attached to the stomach-tube, and the end of the lateral tube 
is placed in a pan of warm water (Fig. 109). By raising the piston and 
openmg the valve water may be drawn from the basin, and by closing 
the valve and depressing the piston it is passed through the stomach- 
tube mto the stomach : when a sufficient quantity has been injected in 
this manner, by reversing the action of the valve the fluid is drawn out 



VAGCiyATION. 99 

of the stomach and discharged through the lateral tube into a basin. 
This manipulation is continued until the water returns clear and the 
stomach has been completely washed out. 

Fig. 109. 




The stomach-pump. 

(Esophageal Bougie. 

This instrument — which may be passed through the oesophagus into 
the stomach for the purposes of diagnosis or for dilating strictures of 
the oesophagus — is passed in exactly the same manner as the stomach- 
tube, and, as in the case of the latter instrument, it should be introduced 
without much force, as perforations of the oesophagus have followed the 
forcible introduction of such bougies. 

Vaccination. 

The surface may be prepared for the reception of the lymph by 
abrading the surface of the skin at one or two points with a dull lancet, 
or by making several superficial incisions, or by scratching the surface 
of the skin with the ivory point charged with lymph in lines with cross- 
ing lines, cross-scratch, until a little serum exudes. It is not advisable 
to draw blood, which washes away the lymph, and for this reason I 
prefer the abraded surface made by the dull knife or the ivory point. 

The lymph employed may be the humanized or the bovine. The 
humanized lymph may be the viscid fluid taken from the vaccine vesi- 
cles on the eighth or ninth day, or the dry scab which separates when 
the wound is healed ; if the latter is used, a small portion of it is rubbed 
up with water until it forms a mixture of creamy substance ; this is 
rubbed into the abraded surface or the punctures. In using humanized 
lymph care should be taken to see that it is procured from a healthy 
subject. 

Bovine lymph or virus, which is now most generally employed, is 
taken from the vaccine vesicles upon the udder and teats of heifers ; 
ivory points or quills are dipped into this lymph and allowed to dry, and 
in using them they are dipped in water for a moment, to moisten the 
lymph, before being applied to the abraded surface. The ivory point is 
one of the mo.st convenient means of vaccinating, as the surface may be 
abraded with it before the lymph is applied. 



100 MINOR SURGERY. 

It has recently been advised that antiseptic precautions be exercised 
in performing vaccination, and, although all of the details cannot be 
carried out, I have found that the exercise of care as regards cleanliness 
of the surface has been followed by much fewer inflammatory complica- 
tions in vaccination-wounds. In performing vaccination the surface to 
be abraded, usually the left arm below the deltoid, is first washed with 
soap and water and then with a 1 : 2000 bichloride solution. Two points 
of this surface, an inch apart, are then abraded by using a knife which 
has been washed or dipped in boiling water, or by using the ivory point, 
which has been dipped in water that has been boiled and cooled down. 
When the surface has been prepared in the manner described moistened 
virus is rubbed upon it and allowed to dry. Vaccination upon the leg, 
which is practised by some physicians to prevent the scar from showing, 
is not always to be recommended, since it is more difficult to keep this 
part at rest, and some very severe cases of cellulitis and phlebitis have 
been observed following leg-vaccination. 

Hypodermic Injections. 

The syringe employed in making hypodermic injections is provided 
with a perforated needle, which is passed into the cellular tissue (Fig. 
110). Care should be taken to see that the instrument and needle are 

Fig. 110. 





Hypodermic syringe and needles. 

perfectly clean before being used : if a metallic syringe is employed, it 
should be rendered aseptic by soaking it for a few minutes in boiling 
water or in a 5 per cent, carbolic solution. Hypodermic injections are 
generally made into parts in which the cellular tissue is abundant, and 
great care should be observed to avoid introducing the needle into a large 
vein or artery, as by neglect of this precaution serious symptoms have 
resulted from the drug being thrown rapidly into the circulation instead 
of being slowly absorbed from the subcutaneous cellular tissue ; injury 
to superficial nerves should also be avoided. Care should also be taken 
to see that the solutions employed are sterilized if possible, and freshly- 
made solutions should be preferred. An unclean syringe or a solution 
which has not been sterilized may give rise to a troublesome abscess at 
the seat of the injection. 

To avoid using for hypodermic use solutions which undergo change 
from being kept, it will be found convenient to use the compressed pel- 
lets which are prepared by the manufacturing chemists, the alkaloids 



EXPLORING NEEDLE AND TROCAR. 101 

being compressed with a little sulphate of sodium, which increases their 
solubility, the solution being prepared with boiled water just before being 
used. The portions of the body usually selected for hypodermic injec- 
tions are the outer surface of the thighs or arms and the anterior surface 
f the forearm. In making a hypodermic injection the syringe is charged 
and the needle is fastened to the nozzle of the syringe ; the skin is next 
pinched up and the needle is quickly thrust through this into the cellular 
tissue (Fig. Ill): the syringe is then emptied by pressing down the 

Fig. 111. 



(I 




Method of giving a hypodermic Injection. 



piston, and when the syringe is empty the needle is withdrawn ; the 
small puncture in the skin resulting seldom bleeds and usually heals 
without difficulty. 

ExPLOEiNG Needle and Tbocab. 

The exploring needle consists of a fine-grooved needle fitted into a 
handle (Fig. 112), and is introduced into tumors or swellings to ascer- 
tain the nature of their contents. 

Fig. 112. 



^ 



Exploring needle. 



The exploring trocar (Fig. 113) is employed for the .same purpose, 
or the needle of a hypodermic syringe or a fine needle attached to an 



Fig. 113. 




Exploring trocar. 

aspirator may be used for a like purpose. When either the exploring 
needle or trocar is employed care should be taken to see that it is ren- 
dered perfectly aseptic before being used ; otherwise its employment is 
not without danger. 

The Clinical Thbrmometbe. 

For clinical observations two thermometer scales are in general use — 
the Centigrade and the Fahrenheit ; the latter is the one commonly em- 



102 MINOR SURGERY. 

ployed in America and England. This scale has a limited range above 
and below the normal temperature, which is 98|-° Fahrenheit or 37° 
Centigrade. Thermometers are now made with a convex surface, which 
serves to magnify the column of mercury, and thus enables the observer 
without difficulty to note the position of the index (Fig. 114). 





Fig. 114. 










—^^^^—~ — -^ -^ ^-^ |""i '""1 ' i"'' 1 ' ' ' ' 1 ' I ' ' '|"'i ^ 


^B^ai^-^ ^"^ - HO 


5 


100 


5 


110 


^ 



Clinical thermometer. 

The temperature of the body may be taken in the mouth, axilla, 
vagina, or rectum ; the two former positions are those generally em- 
ployed. When taken in the axilla, care should be exercised to see that 
no clothing is interposed between the skin and the instrument, and when 
the mouth is used for thermometric observations, the patient should be 
instructed to keep his lips tightly closed and breathe through his nose. 
The thermometer should be kept in place from three to five minutes. 

Surface Thermometer. 

Surface thermometers are sometimes employed, the instruments for 
this purpose having bulbs of a discoid shape (Fig. 115) or are drawn 
out in the form of a spiral or coil. 

Fig. 115. 




Surface thermometer. 



In using this form of thermometer to determine the amount of vari- 
ation of the surface temperature, the temperature of corresponding parts 
of the body on the opposite side and the general temperature of the body 
should be taken at the same time. 

The Rectal Tube. 

The introduction of the rectal tube is best accomplished by placing 
the patient upon his left side. The surgeon should introduce his index 
finger well oiled into the rectum and guide the tube upon this : if a stric- 
ture exists within reach of the finger, the latter should be used to guide 
the tube through the opening in this ; if the tube becomes caught in a 
transverse fold of the mucous membrane and becomes doubled upon 
itself, it should be withdrawn and a fresh attempt should be made to 
pass it. In passing a rectal tube all manipulations should be made with 
extreme gentleness, since its passage is not without danger, perforations 
of the intestine having followed its use in some cases. In cases of stric- 
ture of the rectum high up the operator has to depend upon the sense of 
resistance experienced in passing the tube, and in such cases the manip- 
ulations should be most carefully made. When the rectal tube is em- 
ployed to introduce fluids into the large intestine, the fluids may be 



ENEMATA. 103 

introduced by means of a syringe, or by pouring them into a funnel 
attached to the free end of the tube, or by attaching the tube to a foun- 
tain-syringe, thus allowing the fluid to pass slowly into the intestine. 

The rectal tube is often employed with good results in relieving the 
intestine of excessive flatus and in introducing water or oil into the 
intestine in cases of intestinal obstruction, and in those cases where 
obstruction results from intussusception or fecal accumulations its use 
will often prove most satisfactory. 

Rectal Bougies. — These instruments are made of the same material 
as the English flexible catheters and are of various sizes. Before being 
used they should be warmed and oiled, and then carefully introduced 
in the same manner as the rectal tube. They are generally employed in 
cases of stricture of the rectum, and they should be used with great care 
to avoid perforating the Avail of the rectum. A very satisfactory substi- 
tute for a rectal bougie is a tallow candle, one end of which is melted or 
rubbed down to a conical shape. 

Enemata. 

An enema may be administered by means of an ordinary syringe or 
by means of a gravity or fountain-syringe, care being taken to introduce 
the nozzle of the syringe gently and in the right direction, as perforation 
of the lower portion of the rectum has taken place from the careless and 
forcible introduction of the nozzle of the enema-syringe ; the fluids 
should also be injected slowly, as by so doing there is less resistance and 
less tendency for the patient to pass the fluid before the desired quantity 
has been introduced. 

The enema most commonly employed to emptj' the lower bowel is 
made by adding a tablespoonful of sweet oil and two teaspoonfuls of 
spirits of turpentine to one or two pints of warm water in which a little 
castile soap has been dissolved ; warm water and sweet oil are also fre- 
quently employed for the same purpose. 

Glycerin Enema. — One or two teaspoonfuls of glycerin injected into 
the rectum or a suppository containing glycerin will often be found an 
efficient substitute for the larger enemata of water, but it is more liable 
to produce tenesmus. 

Nutritious Enemata. — When it is found necessary to resort to feed- 
ing by means of the rectum care should be taken that the quantity is 
not too large, and that it is of such a nature as not to cause any irrita- 
tion of the walls of the rectum, or it will not be retained ; two ounces in 
the case of an adult is generally sufficient to inject at one time. 

Peptonized milk or beef-juice, or the yolk of an egg beaten up with 
milk, is often employed, and any unirritating drug may be mixed with 
the enema and administered at the same time. 

Massage. 

Under the general term " massage " a variety of manipulations are 
employed with advantage in the treatment of surgical aifections. These 
consist in effleurage (or stroking), petrissage (or kneading), tapotement 
(tapping or percussion), and passive and active motion. Another variety 



104 MINOR SURGERY. 

of massage consists in pinching up the integuments and muscles, the 
latter singly or in groups, and rolling them gently between the thumb 
and fingers. Before applying massage to an affected part, if there be a 
heavy growth of hair it should be carefully shaved off, otherwise the 
manipulations will give the patient pain, and irritation of the hair-fol- 
licles, resulting in abscesses, will be apt to occur. The part should also 
be rubbed over with olive oil, vaseline, or cocoa-butter before and dur- 
ing the manipulation. Massage is often employed with advantage in the 
treatment of sprains and strains in their subacute and chronic stages, and 
it will be found of great service in the later treatment of fractures in- 
volving the joints or their vicinity, in restoring the motion of the parts, 
as well as in improving the nutrition of the muscles which have become 
wasted from disease. 

Effleurage (stroking) consists in gently smoothing or rubbing the 
surface of the part with the palm of the hand from the periphery ; dis- 
tended veins and lymphatics are thus emptied and liquid transudation 
is removed from the tissues. In the early stages of inflammation strok- 
ing is first applied above the seat of disease in order to afford more space 
for the return currents ; the inflamed part is approached by degrees, and 
when reached firm and gentle pressure is made upon it, thus forcing the 
fluids inward and promoting the absorption of exudations if they have 
already occurred. 

Petrissage (or kneading) is applied by rubbing the parts circularly 
with the extremities of the fingers or thumb or the palm of the hand, 
and is indicated in cases of ecchymosis into subcutaneous cellular tissue 
or in cases of inflammatory transudation. Petrissage may with advan- 
tage be combined with eflBeurage when it is desirable not only to break 
up transudations, but likewise to hasten the removal of the resulting 
detritus from the tissues. The operator has to judge of the amount of 
pressure to be employed in this variety of massage by the nature and 
seat of the material to be gotten rid of and by the sensitiveness of the 
patient. 

Tapotement (or percussion) is applied by tapping the surface of 
the affected part either with the tips of the fingers held in a row, or 
by a small india-rubber hammer, or by the ulnar border of the hand. 
Tapotement, it is claimed, has been used with advantage in neuralgia 
and peripheral palsies, and is thought to bring about good results by 
promoting the absorption of the exudations from around the affected 
nerves. 

Passive and active motion consists in alternately flexing and rotating 
the limb to imitate the normal joint-movements. These motions should 
be carefully practised, and in cases of fracture should not be undertaken 
until there is quite firm union at the seat of fracture, or, if for any 
reason, passive motion is made use of before this time, the fragments 
should be supported while it is being employed. Passive motion asso- 
ciated with massage will often be found of the greatest value in the 
treatment of joints which have been immobilized for a time following 
sprains, fractures, or dislocations. 

JIusde-beating. — This is a form of massage which is practised by the 
use of three elastic tubes fastened together near a handle to which they 
are attached, the size of the tubes and the length and thickness of the 



ELECTRO-THERAPY. 105 

material depending upon the different purposes for which the instruments 
are employed. Muscle-beating, when applied to the general surface, 
should not be made upon the naked skin : the parts should be protected 
by a thin covering of some kind, and the application is to be suspended 
as the sensation of moderate burning or an increase of surface temper- 
ature is felt by the patient. Muscle-beating has been recommended in 
cases of muscular ataxy, in stiffness of the joints following sprains or 
dislocations, in rheumatism, and in lateral curvature of the spine. It 
has the advantage of being a form of massage which the patient himself 
can often employ with advantage. 

Electro-therapy. 

The constant current, galvanism, is often made use of in the various 
paralytic conditions which accompany or follow surgical affections, being 
passed along the course of nerve-trunks to excite their conducting power 
or in neuralgic affections to act as a sedative. 

Faradization. — Electricity in the form of the induced current, far- 
adisra, is often employed in surgical affections where the tonic and 
stimulating effects are chiefly desired : in cases of wasting of the mus- 
cles following fractures or sprains, in some forms of club-foot, and in 
lateral curvature of the spine the judicious use of the faradic current 
will often be found to be followed by the most satisfactory results. The 
current is applied in such a manner as to bring about contraction of the 
affected or wasted muscles, and thus improve their nutrition. 

Franklinization, or Statical Electricity. — The earliest application 
of electricity in the treatment of disease was made by the use of stat- 
ical electricity, and, although it fell into disuse, it has recently, with 
the perfection of modern machines, been very widely revived. In 
applying statical electricity the patient may be treated by insulation 
or the so-called dry electric bath. The second metiiod of using statical 
electricity is by sparks or shocks from a Leyden jar which is charged 
from the prime conductor of an electrical machine in motion or by the 
electric brush. McClure states that in the static induced current we 
have a means of producing muscular contraction when failure results 
from the strongest bearable faradic currents. 

Electrolysis. — Electrolysis, or the chemical decomposition induced 
by electricity, is employed in surgery to destroy morbid products, tumors, 
or exudations. For this procedure the galvanic or continuous current is 
required. In applying electrolysis to a tumor the needle connected with 
one of the poles of the battery is inserted into the tumor and the other 
rheophore is applied to the surface of the body, or two fine needles, care- 
fully insulated nearly to their extremities, are connected with both poles 
of the battery by conducting cords ; these are introduced into the tumor 
and a weak current is allowed to pass, and its strength is gradually 
increased as the operation advances ; the current is passed for fifteen or 
twenty minutes, and the procedure is repeated at intervals of several 
days, until some decided change occurs in the tumor. Electrolysis has 
been applied with success in the treatment of aneurism inaccessible to 
other operative procedures, in malignant growths, in nsevi, in goitres, 
eysts, hydatids, and is at the present time the most satisfactory method 



106 



MiyOR SURGERY. 



of removing superfluous hairs from those parts of the body in which 
their presence causes disiigurement. 

Galvano-cautery. — Galvano-cautery batteries are constructed with 
plates of large size, placed closely together, so that the internal resistance 
is reduced and a current is quickly obtained which will keep a metallic 
electrode at a white heat. The advantage in this form of cautery is that 
the electrode can be introduced into the various cavities of the body 
while cold, and quickly heated to the desired temperature. The elec- 
trodes are made of various shapes and sizes, according to the object 
desired (Fig. 116). 

Fig. 116. 




Electrodes for galvano-cautery. 

Galvano-cautery is applied for the same purposes as the actual 
cautery, but, as previously stated, its use is more convenient in the 
various cavities of the body, its action can be more easily localized, and 
by its use hemorrhage is avoided. Galvano-cautery is frequently em- 
ployed to destroy morbid growths in the nasal passages, the throat, 
vagina, or uterus, and also may be employed in the treatment of super- 
ficial external growths : in using it for the removal of growths from the 
mucous membrane its application may be rendered practically painless 
by previously thoroughly cocainizing the parts. 



The Cystoscopb. 

This is an instrument for examining the mucous membrane of the 
bladder, and is one of the most important and useful of the electric-lamp 
instruments, because it aifords information which cannot be obtained 
without it. A cystoscope consists of a beak sound in which there is a 

Fig. 117. 




Letter's cystoscope. 



telescopic arrangement by which the surface of the bladder is viewed 
through a small window of rock crystal. The lamp is enclosed in the 
beak of the mstrument and throws its light through another window 



THE URETHROSCOPE. 107 

also of crystal, upon the part of the bladder-wall. For examining the 
upper part of the bladder a separate instrument with a small reflecting 
prism is used. The bladder must contain six or eight ounces of clear 
urine or clear water if a proper view of the walls is to be obtained. If 
the fluid present is turbid, the view is very much obscured ; if too little 
fluid be present in the bladder, the beak of the instrument with the 
lamp is likely to become buried in the folds of the mucous membrane 
and the light will be cut off, and in that case the mucous membrane may 
be burned. A certain amount of practice is required to use the cysto- 
scope properly and to recognize the appearance of the mucous membrane 
of the bladder in health and in its varied morbid conditions. 

The Urethroscope. 

The urethroscope (Fig. 118) consists of a straight metal tube pro- 
vided with a rounded obturator of hard rubber which projects beyond 

Fig. 118. 




The urethroscope. 

the end of the tube. This instrument is introduced into the urethra 
until the bladder is reached, when it is slightly withdi-awn and the obtu- 
rator is removed. The instrument is then attached to a mirror or an 
electric lamp, by which a strong light is thrown into the tube, and as the 
tube is withdrawn various portions of the urethra are exposed to the 
view of the surgeon. By means of the urethroscope a very accurate 
inspection of various portions of the urethra can be obtained. 

The Panelectroscope. 

This instrument, introduced by Leiter, consists of a lantern with a 
handle and mirror. The light from a small incandescent lamp is pro- 
jected by the mirror along the tube, which is inserted into the part to 
be examined. Tubes of various sizes are adapted to the instrument, and 
it is especially useful for endoscopy of the urethra, and it is also airanged 
for examining the ear, the pharynx, and stomach. 

Local Anesthesia. 

Cold. — Local anaesthesia may be produced by the application of cold, 
either by a piece of ice or by a mixture of ice and salt held in contact 



108 MINOR SUBOEBY. 

with the part for one or two minutes, or by directing a spray of rhigo- 
lene upon the surface of the part whose sensibility is to be obtunded. 

Sulphuric ether, used as a spray for a few seconds upon the surface 
of the body, will produce complete ansesthesia. Chloride of ethyl is 
also used to produce local ansesthesia, and is conveniently furnished in 
glass tubes, one end of which is drawn out into a fine point and her- 
metically sealed ; when used the end of the tube is broken off and a fine 
jet of ethyl is projected upon the surface, the warmth of the hand being 
sufficient to force the fluid from the tube. This form of local anaesthe- 
sia is made use of in minor surgical procedures, such as aspiration, the 
opening of abscesses, and the removal of superficial tumors. 

Rapid Respiration. — Rapidly-repeated deep inspirations kept up for 
a few minutes will produce insensibility to pain, but sensibility to con- 
tact is not obliterated. This form of ansesthesia may be made use of in 
slight operations, such as the opening of abscesses. 

Cocaine. — Local ansesthesia, produced by the employment of an 
aqueous solution of the hydrochlorate of cocaine, in strength from 2 to 
12 per cent., is often made use of in minor surgical procedures where 
the mucous membrane is to be operated upon or growths removed from 
it. Analgesia is produced by brushing the surface over with the solu- 
tion of cocaine or by applying a compress of absorbent cotton saturated 
with the solution to the part for a few minutes ; in mucous cavities the 
latter method of application will be found most convenient. In using a 
solution of cocaine to produce ansesthesia in operations upon the eye a 2 
or 4 per cent, solution is dropped into the eye, and the application is re- 
peated until the analgesia is complete. 

In applying cocaine to the urethra a 4 to 10 per cent, solution is 
injected into the urethra, and is allowed to remain for two or three 
minutes : more than one or two grains should not be injected at one 
time, for fatal results have followed the injection of larger quantities 
into this organ. 

When it is desired to produce local ansesthesia of the skin or deeper 
tissues, the application of cocaine to the surface is not satisfactory, and 
it should in such cases be introduced hypodermically into the deeper 
layers of the skin and into the cellular tissues of the parts to be operated 
upon : to avoid multiple puncture the needle is not completely with- 
drawn from the wound, but its direction is changed, and the solution is 
thrown into the different portions of the tissues. It is well, in situations 
where it can be accomplished, to cut off the circulation from the part to 
be operated upon by placing around it a rubber strip or tube, which pre- 
vents its rapid absorption into the general blood-current. It is well not 
to inject more than one grain of the drug in that way, for fatal results 
have followed the injection of larger quantities, and great care should 
always be exercised in using cocaine hypodermically. 

Some persons have an idiosyncrasy for cocaine, and children seem 
more susceptible to its constitutional effects than adults. The author 
has seen several cases in children in which marked symptoms of cocaine- 
poisoning have resulted from the application of a 4 per cent, solution to 
the nasal mucous membrane. 

In minor surgical operations, such as amputations of the finger, cir- 
cumcision, opening of abscesses, and the removal of superficial tumors 



CATHETERS. 109 

cocaine anaesthesia may be employed with advantage, but its utility is 
most marked in operations upon the eye and those upon the mucous 
membrane of the nose, throat, rectum, vagina, and urethra. A 4 per 
cent, solution applied for a few minutes to the surface of an ulcer which 
is to be cauterized will render the operation almost painless. 

Catheters. 

Catheters are hollow tubes, made either of metal, india-rubber, linen 
and shellac, or other flexible substances. 

Metallic catheters are made of silver, or, if constructed of other 
metals, they should be plated with silver or nickel to give them a 
smooth, bright surface which can easily be kept perfectly clean ; and 
their shape should conform to that of the normal urethra (Fig. 119). 

Fig. 119. 




Metallic catheter. 



The shape of the metallic catheter is sometimes changed to meet certain 
indications ; for instance, the metallic catheter for use in cases of en- 
larged prostate is longer and has a larger curve than the ordinary instru- 
ment (Fig. 120). The metallic catheter for the female is shorter and 
has a much smaller curve than the instrument used for the male urethra. 



Fig. 120. 




Prostatic catheter. 

Flexible Catheters. — The most commonly used variety of flexible 
catheter is that known as the English catheter, which is made of linen 
and shellac, and is provided with a stylet ; it can be moulded into any 
shape desired by dipping it in hot water, which renders it very flexible, 
and, after moulding it to the proper curve, this can be fixed by im- 
mersing it in cold water, which hardens it again. 

The French flexible catheters are made of india-rubber or a com- 
bination of this material with other substances. These instruments are 
conical toward their extremities, and terminate in an olive-shaped point, 
and they are provided with one or two smoothly finished eyes near their 
vesical extremities (Fig. 121). 



110 



MINOR SUBOEBY. 



Another form of flexible catheter, known as the elbowed catheter or 
Mercier's catheter (Fig. 122), has an angle or elbow near its vesical ex- 



FiG. 121. 



French flexible catheters. 



tremity ; this is often found a satisfactory instrument to use in cases of 
enlarged prostate. A variety of flexible catheters made of soft india- 
rubber is also sometimes employed (Fig. 123). 



Fig. 122. 



Mercier's elbowed catheter. 



Catheters and bougies are made according to a certain scale. The 
English scale runs from 1 to 12, the American from 1 to 20, and the 
French from 1 to 30. 



Fig. 123. 




Soft-rubber catheter. 



Bougies. — Bougies are flexible instruments which correspond in size 
and shape to the English and French catheters, and besides these are the 
acorn-pointed bougies (Fig. 124), and the filiform bougie, which is made 



Fig. 124. 



^C) 



Bulbous or acorn-pointed bougies. 



of wlialebone or of the same material as the ordinary French bougie and 
catheter. Filiform bougies are of very small size, and can often be 
passed through strictures whicli will admit the passage of no other form 
of instrument (Fig. 125). Bougies are employed in the treatment of 
strictures of the urethra bv dilatation. 



CATHETERS. 



Ill 



Sounds. — Sounds are solid instruments made of steel with a smooth 
surface and plated with nickel ; they correspond in size to, and have the 



Fig. 125. 



Filiform bougies. 



same curve as the metallic catheter ; the handle is flattened to allow the 
operator to grasp them firmly, and they are employed in the treatment 
of strictures by dilatation (Fig. 126). A special sound, which is straight 



Fig. 126. 




steel sound. 



and is shorter than the sound employed in the treatment of urethral 
strictures, is used in dilating strictures of the meatus (Fig. 127). 



Fig. 127. 




Sound for dilating meatus. 



Introduction of a Catheter. — The passing of a catheter is a minor 
surgical procedure which every practitioner is at times called upon to 
employ, and in a healthy urethra it is a matter of little difficulty. 
For the introduction of a catheter the patient may be in the stand- 
ing, sitting, or recumbent posture, and the latter is the best in most 
cases ; he should rest squarely on his back and should have the thighs a 
little flexed and separated. Before passing a metallic catheter the sur- 
geon should see that it is perfectly clean, and after warming and oiling 
it he stands upon the left side of the patient, grasps the penis with 
the left hand, and turns it over the pubis, introduces the beak of the 
catheter into the meatus, and gently passes it along the urethra until its 
point passes beneath the symphysis pubis ; at this point the handle is 
elevated and gently depressed between the thighs, and the beak will pass 
into the bladder (Fig. 128). When the prostatic region is reached^ dif- 
ficulty is sometimes experienced in passing the catheter; this is especially 
the case if the prostate gland is enlarged : this may be overcome by intro- 
ducing the finger into the rectum and guiding the catheter through this 



112 



MINOR SURGERY. 



region, or if the prostate is very much enlarged the catheter should be 
withdrawn and a prostatic catheter should be substituted for it (Fig. 120). 
The same manipulation is made use of in passing metallic sounds. 



Fig. 128. 




Introduction of catheter (Voillemier). 

Flexible catheters and bougies are passed by grasping the penis and 
holding it in such a position that it is at a right angle to the axis of the 
body, and the catheter or bougie is passed into the meatus and carried 
through the urethra into the bladder by gently pushing the instrument 
downward. In this variety of catheter, which has no curve, the surgeon 
has no means of guiding the point of the instrument, and if an obstruction 
is met he should withdraw the instrument slightly and make another 
attempt ; all manipulations should be extremely gentle. 

Passing the Female Catheter. — This instrument should be introduced 
without exposure of the patient, she being in bed with the thighs slightly 
flexed and separated from each other. The surgeon introduces tiie fore- 
finger of the left hand between the nymphse, bringing it from behind 
forward until he touches the space between the entrance to the vagina 
and the orifice of the urethra ; the catheter is then introduced with the 
right hand held as shown in Fig. 129, and, guided by the left forefinger,, 
is passed through the orifice of the urethra into the bladder. 



CATHETERS. 



113 



Tying Male Catheter in the Bladder. — When it is desirable to retain 
a catheter for some time in the male bladder, it is necessary to secure it 
to prevent its slipping out. Either a metallic or flexible catheter may be 
employed, but, as a rule, the flexible instrument is to be preferred. There 



Fig. 129. 




Method of holding female catheter. 



Fig. 130. 




Tying in catheter (Bryant). 



are several methods of securing it in the bladder. One method consists 
in taking two narrow strips of tape, or two or three strong silk liga- 
tures attached to the rings at the end of a metallic catheter or securely 
fastened around the end of the flexible instrument, and these are next 
brought backward, one on each side of the penis, and the skin is drawn 
forward, and a strip of adhesive plaster half an inch in width is passed 
■over the ligatures or tapes and carried three or four times around the body 
of the penis just behind the position of the 
glans penis. If the skin has been brought well 
forward before the straps have been applied, 
the ligatures are tightened as it slips back, and 
the catheter has not too much play (Fig. 130). 

Another method consists in fastening a 
strong silk ligature around the catheter just 
in advance of the meatus ; the two ends are 
next brought backward and tied in a knot 
behind the corona glandis ; the ends are then 
carried around behind the corona and tied on 
one side of the frsenum ; the foreskin is slipped forward and covers the 
ligatures. 

Catheters may also be secured in the bladder by tying the ends of the 
silk ligatures which are attached to the instrument in advance of the 
meatus to tufts of pubic hair. A simpler method of securing a flexible 
catheter is to perforate the free end with a needle armed with a double 
ligature of silk or hemp ; the needle being removed, two loops are made 
of the proper length, and these are passed through the ends of a T-bandage, 
which is secured around the waist, the tails being brought up on either 
side of the scrotum and secured to the body of the bandage passing 
around the waist. 

In the female bladder, when it is desirable to keep the bladder empty, 
the self-retaining catheter is employed, which consists of a catheter with 
a bulb at its vesical extremity, or an ordinary catheter with silk loops and 
a T-bandage may be employed in the same manner as in securing the 
male catheter. 

Vol. II.— 8 




114 MINOR SUBGEBY. 

Washing Out the Bladdeb. 
This procedure may be required in the treatment of cystitis, and it is 
accomplished by passing a flexible catheter with a large eye into the 
bladder, or a double catheter may be employed. A syringe, or, better, a 

rubber bulb, holding about a pint, having 
Fig. 131. a nozzle and stopcock (Fig. 131)_, is filled 

with warm water or with any medicated so- 
lution which is desired, and it is then at- 
tached to the free end of the catheter, and 
the contents are gently injected into the 
bladder; care should be taken that the 
Eubber ba| ^^ithj^^f gfo^^J""^ ^<^^- bladder is not too much distended. When 

the desired amount of liquid has been 
injected, the bulb or syringe is removed, and the fluid is allowed to run 
out of the catheter, and the procedure may be repeated until the solution 
comes away perfectly clear. 

If it is desirable to have the bladder perfectly emptied of the solu- 
tion, the operator should compare the amount of fluid injected with that 
which escapes, and in cases of paralysis of the bladder, where the fluid 
injected does not escape, gentle pressure should be made upon the abdo- 
men over the pubis to facilitate its removal. Solutions of boric acid, 
permanganate of potassium, and weak solutions of carbolic acid and of 
nitrate of silver are often employed in washing out the bladder in cases 
of chronic cystitis. 

Uebthbal Injections. 

As urethral injections are usually made by the patient himself, he 
should be shown or instructed how to employ them. A rubber syringe 
having a conical nozzle and holding about two or three drachms is the best 
instrument to employ for this purpose (Fig. 132). The syringe having 

been filled with the solution, the patient,. 
Fig. 132. sitting upon the edge of a hard chair with 

the thighs separated, grasps the syringe be- 
tween the thumb and middle finger of the 
right hand, the tip of the index finger rest- 
urethrai syringe. i^g Upon the end of the piston, and inserts, 

its conical nozzle from a quarter to half an 
inch within the meatus, which is held open by the thumb and finger of 
the left hand ; and after its introduction the meatus should be drawn 
tightly around it, the pressure being made laterally so as to narrow the 
aperture instead of broadening it, as is the case when the compression is 
in an antero-posterior direction. After the fluid has been thrown into 
the urethra in this manner, the syringe is removed, and the patient is 
instructed to hold the lips of the meatus together for one or two minutes 
to prevent the escape of the fluid. 

SyTTJBES. 

A variety of materials are employed for sutures, such as silk, catgut, 
kangaroo-tail tendon, silver or iron wire, silkworm gut, and horse-hair ; 
the material most frequently employed at the present time is either cat- 




SURGICAL NEEDLES. 115 

gut, silk, or silkworm gut, although some surgeons still prefer metallic 
sutures. Catgut and kangaroo-tail tendon are practically the only sub- 
stances employed as sutures which are absorbent; other varieties of 
suture require removal after their application, although some sutures, 
such as silk or silkworm gut, when employed in deep wounds, may 
have their ends cut short, and, if the wound remains aseptic, they are 
apt to become encysted and produce no trouble. It matters little what 
material be employed for sutures if the surgeon is careful to see that it is 
thoroughly aseptic before being brought in contact with the wound. 

Sutures of Coaptation. — These are superficial sutures applied closely 
together, and include only the skin ; they are employed to secure accurate 
apposition of the cutaneous surface of wounds. 

Sutures of Approximation. — These are sutures which are applied deeply 
in the tissues to secure approximation of the deep portions of a wound ; this 
object is accomplished by the use of the quilled, button, or plate suture. 

Sutures of Relaxation. — These sutures are entered and brought out at 
some distance from the edges of the wound, and are employed to prevent 
dangerous tension upon the sutures which approximate the edges of the 
skin. The quilled, button, or plate suture is suitable for this purpose. 

Secondary Sutures. — These sutures are applied when the surfaces of 
the wound are covered by granulations, when the primary sutures have 
failed to secure apposition of the edges of the wound, or in cases of 
secondary hemorrhage where the opening of the wound has been neces- 
sitated to turn out the blood-clot and secure the bleeding vessel, or in 
plastic operations where the primary sutures have failed to secure appo- 
sition of the edges of the flaps. They are also employed with advantage 
in cases in which it is necessary to pack a wound with antiseptic gauze, 
or to allow haemostatic forceps to remain clamped upon bleeding tissues 
in a wound at the time of operation. The sutures should in such a case 
be introduced and loosely tied at this time, and when the packing or 
forceps is removed at the end of two or three days the sutures are 
tightened so as to secure apposition of the edges of the wound. 

Surgical Needles. 

Needles for surgical use are of different sizes and shapes (Fig. 133) : 
straight needles, triangular-pointed, are the ones most commonly em- 
ployed, but curved needles will be 

found most convenient for the in- ■^^®" ^^^■ 

troduction of sutures in wounds 
of certain locations. The ordinary 
round sewing needle is the needle 
usually preferred in the introduc- 
tion of sutures in intestinal wounds. 
Tubular needles are often employed 
in introducing sutures in wounds 
in which the use of an ordinary 
needle is difficult ; for instance, in 
the operation for cleft-palate and 
for the introduction of sutures in deep wounds a mounted needle will 
often be found very useful (Fig. 134). 




Surgical needles. 



116 



MINOR SUBOEBY. 



Calyx-eyed needles, which are threaded by being pushed down upon 
the suture, are sometimes useful. Hagedorn's needles, either straight or 



FiH. 134. 




Mounted needle. 



curved, which are flat and easily penetrate the skin and make a small 
clean wound, are often employed with advantage. Surgical needles 
should be sharp and clean, and should be rendered thoroughly aseptic 



Fig. 135. 




Needle-holder. 



before being used. A needle-holder (Fig. 135) is often required for the 
satisfactory introduction of sutures in wounds of certain localities. If 
this is not at hand, the needle may be held by a pair of dressing forceps 
or a pair of haemostatic forceps. 



Method of Securing Sutuees and Ligatures. 

Metallic sutures are usually secured by twisting the ends together or 
by passing the ends through a perforated shot and clamping the shot with 
a shot-compressor, which securely fixes them. 

Sutures of catgut, silk, silkworm gut, kangaroo-tail tendon, or horse- 
hair are secured by tying, and several different knots are employed to 
secure them. These sutures may also be secured by clamping with per- 
forated shot. 

Reef or Flat Knot. — This is one of the best forms of knot to use in 
securing ligatures or sutures, and is made by 
passing one end of the thread over and 
around the other end, and the knot thus 
formed is tightened ; the ends of the thread 
are next carried toward each other, and the 
same end is again carried over and around 
the other, and when the loop is drawn tight 
we have formed the reef or flat knot (Fia:. 
136). ^ ^ 

Eeef or flat knot. Surgeon's Knot. — This knot is formed by 

carrying one end of the thread twice around 
the other end, and after tightening this loop the same end is carried over 



Fig. 136. 




VARIETIES OF SUTURE. 



117 



and around the other end, as in the ease of the final knot of the reef or 
flat knot (Fig. 137). The surgeon's knot and reef knot combined form 



Fig. 137. 



Fig. 138. 





Surgeon's knot. 



Surgeon's and reef knot combined. 



one of the best methods of securing sutures or ligatures of catgut or 
silk, as tlie first knot is not apt to relax before the second knot is ap- 
plied (Fig. 138). 

Granny Knot. — This method of tying the ligature or suture should 
not be employed, as the resulting knot is not as secure as the reef knot, 
and is apt to relax : it differs from the latter in the fact that, one end of 
the thread having been carried across and around the other end, the knot 
is completed by carrying the same end under and around the other end 
of the thread (Fig. 139). 

Fig. 140. 





Granny knot. 



Staffordshire knot. 



Staffordshire Knot. — This knot is much used to fasten the liga- 
tures securing the pedicle in the removal of the ovaries or ovarian 
tumors ; it is applied as follo-vvs : A mounted needle armed with a stout 
silk ligature is passed through the pedicle, and then withdra-wn so as to 
leave a loop on the distal side ; this loop is drawn over the ovary or 
tumor, and one of the free ends is passed through it, so that one end is 
above, while the other is below, the retracted loop (Fig. 140). The ends 
are then seized and drawn through the pedicle ; at the same time the 
thumb and forefinger are pressed against it until sufficient constriction is 
made, and the ends are finally secured by tying as in the securing of an 
ordinary ligature. 

Varieties op Suture. 

The Interrupted Suture. — This variety of suture is the one most 
frequently employed in the apposition of wounds, and consists of a num- 
ber of single stitches, each of which is entirely independent of the others. 
In applying this suture the surgeon holds the edge of the wound with 
the fingers or forceps, and thrusts the needle, previously threaded, through 



118 



MINOR SURGERY. 



the sldn three or four lines from the edge of the wound. He then passes 
the needle from within outward through the tissues of the opposite flap 

at the same distance from the edge of the 
Fig. 141. wound (Fig. 141). A suture may be used 

with a needle threaded on each end, and in 
this case both needles are passed from within 
outward. The sutures may be secured as soon 
as applied, or they may be left unsecured until 
a sufficient number have been introduced, and 
then they may be secured by tying or twisting. 
Care should be taken to see that they make no 
tension on the edges of the wound, and that they 
are so introduced as to make the best possible 
^fe; apposition of the parts. 

; [I Deep or Buried Sutures. — In extensive 

Interrupted suture. 3,nd deep wounds it may be found necessary to 

introduce both deep and superficial sutures, the 
former bringing about apposition of the muscles and deep fascia, the super- 
ficial layer bringing together the superficial fascia and skin. 

The deep or buried sutures are often employed to unite fascia, 
muscles, or tendons, and the best material for this variety of suture is 
either catgut, silk, or silkworm gut. 

Subcutaneous Suture. — Halstead has recommended a subcutaneous 
suture in which the needle is introduced on the under surface of the skin, 
emerging directly at its cut edge, which produces a subcutaneous suture, 
as the knot can be kept under the skin, and if the silk be fine and non- 

FiG. 142. 




Continued or Glover's suture : method of securing. 

irritating it may be encysted or may be cast off after a time. The object 
of the subcutaneous suture is to avoid infection by the skin-coccus, which 
may be carried by the sutures if passed from without inward. 

Continued or Glover's Suture. — This variety of suture is applied 



VARIETIES OF SUTURE. 



119 



in the same manner as the interrupted suture, but the stitches are not 
cut apart and tied ; it is made with silk or catgut, and is secured by 
drawing it double through the last stitch and using the free end to make 
a Icnot with the double portion attached to the needle (Fig. 142). This 
form of suture is often employed in intestinal sutures, or may also be 
employed in bringing about apposition of the edges of wounds in tissues 
of loose structure. 

The Twisted or Hare-lip Suture. — This is a very useful form of 
suture where great accuracy and firmness of apposition of the edges of 
the wound are desired. It is applied by thrusting pins or needles 
through both lips of the wound, the edges being kept in contact over 
the wound by figure-of-8 turns of silk or wire (Fig. 143). The ends of 



Fig. 143. 



Fig. 144. 





India-rubber suture. 



Twisted or hare-lip suture. 

the pins should be cut off by pin-cutters after the sutures are applied, or 
should be protected by pieces of cork or plaster to prevent them from 
injuring the skin of the patient and causing him pain. 



Fig. 145. 




The quilt suture. 



The twisted or hare-lip suture is frequently employed in plastic 
operations about the face and in other parts of the body where accurate 
apposition of the parts is desired. 

The India-rubber Suture. — This is applied by first passing the 



120 



MINOB SURGERY. 



pins or needles through the edges of the flaps, and, instead of the 
twisted figure-of-8 suture of silk, delicate rings of india-rubber are 
employed (Fig. 144). 

The Quilt Suture. — This variety of suture is made with silk or cat- 
gut, and is employed in wounds to effect very close approximation of the 
parts and to prevent bagging ; it is often employed in connection with 
the continued suture, and is applied as shown in Fig. 145. 

The Quilled Suture. — In making use of this suture a needle armed 
with a double thread of wire is passed through the tissues, as in apply- 
ing the interrupted suture, but at a greater distance from the_ edges of 
the wound. Into the loops on one side of the wound is inserted a 
quill or piece of flexible catheter or bougie, and on the opposite side the 
free ends of the sutures are tied around a similar object after being 
tightened (Fig. 146). This form of suture makes deep and equable 

Fig. 146. 




The quilled suture. 

pressure along the whole line of the wound. In applying this suture it 
may be well in some cases to introduce a few superficial interrupted 
sutures along the line of the wound to secure accurate approximation of 
the skin. This form of suture was formerly much employed in cases of 
deep wounds to secure accurate apposition of the deep portions of the 
wound, but recently the introduction of buried catgut or silk sutures 
has largely supplanted the use of this variety of suture. 

Button or Plate Suture. — This suture is applied by passing a needle 

armed with a double thread, as in the case of the quilled suture, the 

ends of the suture being passed through the eyes of a 

button or through perforations in a lead plate before 

being threaded in the eye of the needle. After the 

suture, prepared in this way,' has been passed through 

both sides of the wound, the needle is removed, and the 

free ends of the suture are passed through the eyes of a 

button or the perforations in a lead plate on the opposite 

side of the wound, and are tightened and secured (Fig. 

147). This form of suture may be employed in deep 

wounds to accompHsh the same purpose as the quilled 

suture, and allows the cutaneous margins of the wound 

Button or latesu ^ remain free from compression ; and here, as in the case 

\ure°smith).^"" of the quilled suture, a few interrupted sutures may be 



Fig. 147. 





VASJETIES OF SUTVRE. 121 

introduced between the button or plate sutures to secure accurate apposi- 
tion of the skin surface if desired. 

Tongue-and-Groove Suture. — This variety of suture, devised by 
the late Dr. Joseph Pancoast, consists in 
slipping the margin of the flap, which has *^' 

been bevelled, into a groove made by dis- 
secting up the margin of the skin surround- 
ing the raw surface which is to be covered. 
In applying this suture the wire or thread 
used has a needle applied on each end, and 

after passing the suture so as to secure the Tougue-and-groove suture. 
flaps the free ends are secured over a pad of 
adhesive plaster or a disk of lead or through the eyes of a button 
(Fig. 148). 

Shotted Suture. — This suture receives its name from the way in 
which it is secured : any of the previously mentioned varieties of 
sutures may be employed. After the suture has been passed the needle 
is removed and the ends are passed through a perforated shot ; the ends 
are then drawn upon to bring the edges of the wound in contact, and 
the shot is pressed down to the skin and clamped by means of a shot- 
compressor. The suture is then cut off^ flush with the surface of the 
shot. This method of securing sutures is especially useful in closing 
wounds in mucous cavities, such as the vagina, rectum, and mouth, 
where the knot or twist of the wire might cause irritation of the surface 
or pain to the patient. It is also a useful method of securing sutures 
in plastic operations ; it also facilitates the removal of the sutures, as 
the shot is not apt to be obscured by the swollen tissues, and is easily 
seized by forceps when the loop is divided. 

Removal of Sutures. — Where sutures are buried in the tissues or 
used to approximate parts in cavities which are subsequently closed, 
such material should be used for sutures as will be absorbed in a few 
days or will become encysted and remain harmless in the tissues — cat- 
gut, silkworm gut, kangaroo tendon, or silk ; and it is needless to state 
that sutures used with this end in view should be rendered perfectly 
aseptic before being employed. 

Chromicized catgut sutures, when well prepared and used in external 
wounds, usually undergo absorption in from ten to fifteen days ; the 
loop buried in the tissues is absorbed, and the knot may be removed 
from the surface with forceps or comes ofl" with the dressings. 

Sutures made of other substances, such as silk, silkworm gut, silver 
wire, and horse-hair, are removed by cutting one side of the loop and 
making traction upon the knot of the suture with forceps, or in the case 
of the wire suture, after dividing the loop and straightening out one end 
of it, the wire may be withdrawn in a curved direction. 

Sutures which are not causing any irritation should be allowed to 
remain in position until the wound is solidly healed. The time usually 
required for their retention in cases of aseptic wounds is from four to 
eight days. 



122 



MINOR 8VBGEBY. 



Fia. 149. 




Single ligature with pin (Roberts). 



Ligatures used for the Treatment op Vascular Growths. 

Various forms of ligatures are used for the strangulation of vascular 
growths, and the material used for such ligatures is usually strong silk 
or hemp thread, catgut, or silver wire. 

Single Ligature with Pin. — This is applied by iirst inserting a hare- 
lip pin through the skin near the edge of the growth, passing it under 

the growth and bringing its point out 
through the skin at a point opposite the 
point of entry; a strong silk or hemp 
ligature, which has been well waxed, is 
passed under the ends of the pin sur- 
rounding the base of the tumor, and is 
drawn tight enough to strangulate the 
growth, and is secured by two knots 
(Fig. 149). If the growth is of con- 
siderable size, it is better before applying this ligature to introduce a 
second pin at right angles to the first one, and then secure the ligature 
under the pins. In applying these forms of ligatures to healthy skin 
the patient is saved much pain, and the separation of the mass is hastened, 
by cutting a groove in the skin with a sharp knife at the point where 
the ligature is to be applied ; the ligature when applied is buried in the 
groove thus made. 

Double Ligature. — This ligature is applied by passing a needle or a 
needle with a handle, armed with a double ligature, through the skin 
near the growth, and then passing it under the 
tumor and bringing it out through the skin at 
a point directly opposite the point of insertion ; 
the ligature is then divided and the needle 
removed, and the tumor is strangulated by 
tying firmly the corresponding ends of the 
ligature on each side of the tumor, each lig- 
ature strangulating one-half of the growth 
(Fig. 150). 

Fig. 150. 



Fig. 151. 





Method of applying double ligature (Roberts). 



Double ligature with pin 
(Bryant). 



The double ligature may also be applied by first passing a pin under 
the growth, and then passing a needle armed with a double thread under 
the tumor at right angles to the pin, and after removing the needle the 
ends of the ligature are tied and the tumor is strangulated in two 
sections (Fig. 151). 

Quadruple Ligature. — In applying this ligature two needles carry- 
ing a double ligature are passed under the growth at right angles to 



LIGATURES USED FOB TREATMENT OP VASCULAR GROWTHS. 123 

each other, or if the handled needles be used they may be first passed 
in this manner, and then threaded with double ligatures, which are 
carried under the growth as they are Avithdrawn. The needles being 
removed, the surgeon ties two ends of the ligature together, and repeats 
this procedure until the growth has been strangulated in four sections 
(Fig. 152). 

Fig. 152. 




Quadruple ligature (Liston). 



Fig. 153. 



Subcutaneous Ligature. — This is applied by introducing a needle 
armed with a ligature through the skin near the growth, and carrying 
it through the subcutaneous tissues 
around the growth for a short dis- 
tance, then bringing it out through 
the skin. The needle is again intro- 
duced through the same puncture, 
and is again brought out through 
the skin at some distance from the 
first point of exit, and is next intro- 
duced through this puncture and 
brought out at a more distant point. 
In this way the growth is completely 
encircled by a subcutaneous ligature, 
which is finally brought out at the 
point of entrance ; the tumor is 
strangulated by firmly tying the 
ends of the ligature (Fig. 153). 

If a needle armed with a double 
ligature is first passed under the growth, the ligature is divided, and by 




Subcutaneous ligature (Holmes). 



124 MINOR SUBOEBY. 

passing each end of the divided ligature subcutaneously around the 
growth it may be strangulated subcutaneously in two sections. 

Eriohsen's Ligature. — This ligature is employed to strangulate 
tumors of irregular shape in a number of sections. A strong silk or 
hemp ligature, three yards in length, one-half of which is stained black, 
is carried by a needle as a double ligature under the growth at various 
points, so as to leave a series of loops about nine inches long on each 

Fig. 154. 




Ericliseii's ligature (Erlchsen). 



side of the tumor (Fig. 154) ; the black loops being cut on one side, the 
white on the other, the ends are then firmly tied so as to strangulate the 
growth in sections (Fig. 155). 



Fig. 155. 




Erichsen's ligature applied. 

Elastic Ligatures. — Ligatures made of india-rubber varying from 
half a line to several lines in thickness are often made use of in surgery. 
They may be employed to strangulate growths, such as moles or nsevi, or 
in the treatment of fistulas, and are especially useful in the treatment of 
those cases oi fistula in ano in which the internal opening into the bowel 
is situated high up, as the division of such fistulse by this means is accom- 
plished without hemorrhage and with less risk than by the employment 
of the knife. In applying elastic ligatures in such cases the ligature, 
after being passed through the fistula by means of a probe, is carried out 
through the internal opening ; the anus is next well stretched, and the 
elastic ligature is then firmly tied with two or three knots ; the greater 
the tension made before the ligature is tied the more rapidly will it cut 



GENERAL TREATMENT OF HEMOERHAOE. 125 

its way out. The smaller sizes of rubber drainage-tubes may be substi- 
tuted for the solid rubber ligatures. 

General Treatment of Hemorrhage. 

The surgeon may be called upon to treat the following varieties of 
hemorrhage : arterial, venous, capillary, or parenchymatous ; and these 
are again classified, according to the time of their occurrence, as primary, 
that is, bleeding which occurs at the time the wound is inflicted ; interme- 
diary or consecutive, that which occurs within twenty-four or forty-eight 
hours after the reception of the injury, which generally takes place dur- 
ing the period of reaction ; and secondary, which takes place after forty- 
eight hours, and may occur at any time subsequent to this period until 
the wound is healed. 

The treatment of hemorrhage is either constitutional or local. 

The constitutional treatment of hemorrhage consists in keeping the 
patient in the recumbent posture and avoiding any sudden elevation of 
the head or arms which might induce fatal syncope. Opium is a valu- 
able remedy, and should be freely used. Ergot, gallic acid, acetate of 
lead, and tincture of iron may also be employed, stimulants and food 
should be carefully administered, and in extreme cases auto-transfusion 
or transfusion of blood or of normal salt solution may be resorted to. 

In the local treatment of hemorrhage various measures may be adopted 
■which may be either temporary or permanent in their action. 

Temporary Control of Arterial Hemorrhage. — This may be 
•effected by pressure applied directly to the bleeding vessel in the wound 
or by pressure applied indirectly to the main artery between the point 
of its injury and the centre of the circulation ; and this pressure may be 
made by the fingers, digital compression, by compresses, or by means of 
tourniquets. 

Digital Compression in Hemorrhage. — This constitutes one of the 
most valuable means employed in the temporary control of hemorrhage. 
The finger should be pressed directly upon the bleeding vessel in the 

Fig. 156. 




'.'.qrr^'/M 



""■"'.„„„„',{//., ,„, 



Digital compression of femoral artery. 



wound or be used to make pressure upon the artery from which the 
bleeding arises at some point between the wound and the centre of the 



126 MINOR SURGERY. 

circulation (Fig. 156). Control of hemorrhage by digital compression 
can only be maintained for a few minutes, for the fingers of the surgeon 
or assistant soon become tired, so that it is only employed until means 
are adopted for the permanent control of the bleeding. Digital compres- 
sion of the radial and ulnar arteries is frequently resorted to for the control 
of hemorrhage during amputations of the fingers, also of the axillary and 
femoral arteries in amputations at the shoulder- and hip-joints. Digital 
compression is also used to control hemorrhage from wounds either the 
result of accident or those made by the knife of the surgeon, in which 
case the finger is placed directly upon the divided vessel or is employed 
to hold a sponge or compress firmly in the wound. 

Compresses. — By the use of compresses, placed directly in the wound 
or applied to the vessel between the wound and the centre of the circu- 
lation, the temporary control of hemorrhage may be very satisfactorily 
accomplished. Where it is possible the compress which is applied in the 
wound should be made of antiseptic gauze, thereby diminishing the 
chances of wound-infection. The compress should be held in position 
by a bandage firmly applied, and is generally employed only as a tem- 
porary expedient until a more permanent means of controlling the 
bleeding is adopted. 

Tourniquets. — Tourniquets, which are instruments employed for the 
temporary control of hemorrhage from wounds, are of many different 
kinds. 

Petiis Tourniquet. — Petit's tourniquet, which is the best for ordinary 
use, consists of two metal plates connected by a strong linen or silken 
strap, with a buckle, the distance between the plates being regulated by 
a screw (Fig. 167). In applying this tourniquet a compress or roller 

Fig. 157. 
feeivmiQ 3^ SON 




Petit's tourniquet. 



bandage is placed directly over the artery to be compressed, and may be 
held in position by a few turns of a roller bandage. The lower plate of 



GENERAL TREATMENT OF HEMORBHAOE. 



127 



the tourniquet is placed directly over this pad, and the strap is tightly 
secured around the limb to keep the instrument in place. The screw is 
then turned so as to separate the blades and tighten the straps, thus 
forcing the compress or pad upon the artery, controlling its circulation. 
This instrument is very generally employed for the control of hemor- 
rhage in wounds of the extremities, and it is especially useful in ampu- 
tation of these parts, being placed over the main artery some distance 
above the seat of operation. 

The Spanish Windlass. — An improvised tourniquet, known as the 
Spanish windlass, may be employed in the temporary control of hemor- 
rhage in cases of emergency : it is prepared by folding a handkerchief or 
piece of muslin into a cravat and placing a compress or smooth pebble 

on the body of the cravat ; this is placed over 
the artery to be controlled, and the ends of 
the handkerchief are tied loosely around the 
limb ; a short stick is passed through this loop, 
and by twisting the stick the loop is tightened 
and the compress is forced down upon the 
artery (Fig. 158). 

Fig. 159. 





The Spanish windlass. 



Lister's aorta-compressor. 



Many other forms of tourniquet have been devised which have a pad 
or counter-pad so arranged as to make pressure upon the vessel desired, 
such as Lister's aorta-compressor (Fig. 159), which is employed in the 
treatment of aneurism of the iliac vessels and for the control of hemor- 
rhage in amputation at the hip-joint. Hoey's clamp (Fig. 160) and 
Signorini's tourniquet (Fig. 161) are constructed upon the same prin- 
ciple, and are frequently employed to control the circulation in the 
femoral artery in case of operations upon the thigh and leg, and in the 
treatment of femoral or popliteal aneurism. 

The elastic tube or strap of Esmaroh's apparatus (Fig. 162) may also 
be employed for the temporary control of arterial hemorrhage, being 
applied above the wound, and if this is not at hand any strong rubber 
cord or a piece of large-sized drainage-tube may be used as a substi- 
tute. In hemorrhage from wounds of the hands and feet, especially in 
children, and in controlling hemorrhage in wounds of the penis, a piece 
of drainage-tube firmly applied above the wound may be employed with 



128 



MINOR SURGERY. 



advantage. This tube or strap, although generally employed to control 
hemorrhage from vessels of the extremities, may be used to control the 



Fig. 161. 



Fig. 160. 





Hoey's clamp. 



Signorini's tourniquet. 



femoral artery as it crosses the brim of the pelvis by placing a compress 
over the artery in this position, and then applying the elastic band to 



Fig. 162. 




Elastic strap of Esmarch's apparatus. 

secure it with a figure-of-8 turn, passing it under the thigh, crossing it 
over the pad, and then carrying the ends around the pelvis and securing 
them. 

To make pressure on the axillary artery the compress should be 
placed in the axilla, and the middle of the tube is placed over this to 
hold it in position; the ends of the tube are then carried over the 
shoulder and crossed, and then carried to the opposite axilla and 
secured. 

In amputation of the shoulder-joint, to make pressure upon the 
subclavian artery, which is difficult to compress by an ordinary tourni- 
quet, the handle of a large key well padded may be used ; it is firmly 
pressed against the vessel above the clavicle and held by an assistant, 
and proves a very satisfactory means of controlling circulation in this 
vessel. Wyeth's pins with an elastic strap or tube are now often 



GENERAL TREATMENT OF HEMORRHAGE. 



129 



employed to control hemorrhage during amputation at or near the 
shoulder-joint. 

Hcemostatic Forceps. — The temporary control of arterial hemorrhage 
by the use of hsemostatic forceps is now the common practice in 
surgical operations, and their use has done much to diminish the shock 
from the loss of blood following operations. The hsemostatic forceps 

Fig. 163. 




Haemostatic forceps. 

in general use is self-retaining ; it is clamped upon the bleeding vessel, 
and is allowed to remain until the operation is completed, when the 
vessel is secured permanently by the application of a ligature and the 
forceps is removed. The use of this instrument will be found very 
satisfactory in controlling hemorrhage during the removal of tumors 
and in cases of amputation, and for the temporary control of bleeding 
during the operation of tracheotomy it will be found most efficient, as 
also in abdominal operations, in which its utility was first demonstrated 
(Fig. 163). 

Esmarch's Bandage and Tube. — Esmarch's apparatus, which is 
applied to the limbs to render them bloodless during operations, con- 
sists of a rubber bandage two and a half inches in width and three 
or four yards in length, and a rubber tube two yards in length, to one 

Fig. 164. 




EBtnarch's bandage and tube applied. 



end of which is attached a chain and to the other end a hook, or, better, 
a rubber strap one inch in width and one yard in length, with a hook 
and chain. The bandage is applied to the extremity of the limb, and is 



Vol. II.— 9 



130 MINOR SUROEBY. 

carried up the limb to a point some distance above the seat of proposed 
operation : the bandage is applied firmly, each turn overlapping one- 
fourth of the preceding one, and when the last turn has been made the 
rubber tube or strap is wound iirmly around the limb, and is secured by 
fastening the hook into one of the links of the chain (Fig. 164). After 
securing the tube or strap the rubber bandage is removed from the limb, 
and if the tube has been firmly enough applied the limb will be found 
to be blanched, and should be free from blood during the operation. 
Care should be taken not to apply the tube or strap too tightly in 
poorly-developed lunbs or on parts of the limb where large nerve- 
trunks approach the surface, as they may be subjected to an amount 
of pressure which will interfere with their functions subsequently : the 
writer has knowledge of one case of this nature in which permanent 
paralysis of the limb followed the use of Esmarch's apparatus. The 
tube should be applied with just enough firmness to control the circula- 
tion. As the strap, when firmly applied, completely cuts oif the circu- 
lation of the parts below, it should be allowed to remain for as short 
a time as possible, as gangrene has resulted from its prolonged use. 

After the removal of the tube there is generally quite free capillary 
hemorrhage, due to paralysis of vasomotor nerves from pressure, but 
this in a short time stops, especially if hot water is used to irrigate the 
wound. This apparatus is of the greatest service in controlling hemor- 
rhage at the time of operation, and in amputations and removal of A'as- 
cular tumors from the limbs will be found most satisfactory. In 
operations upon bone, either osteotomy or sequestrotomy, it is espe- 
cially useful, as it allows the surgeon to have a view of the parts 
unobscured by hemorrhage. In operations for the removal of foreign 
bodies, such as needles imbedded in the hands or feet or extremities, 
Esmarch's bandage is most useful. 

Permanent Control or Arterial Hemorrhage. — For the per- 
manent control of arterial hemorrhage the surgeon may resort to the use 
of position, cold, heat, styptics, pressure, cauterization, ligation, torsion, 
or acupressure. 

Position. — In arterial hemorrhage from wounds of the extremities 
elevation of the parts will be found to materially duninish the amount 
of bleeding ; in hemorrhage from wounds of the hand, forearm, foot, or 
leg forcible flexion of the forearm on the arm or of the leg on the thigh 
will be found useful in diminishing the force of the blood-current. 

Gold. — The application of cold by means of a stream of cold water 
or of an ice-bag or piece of ice will often be found an efficient means 
of controlling arterial hemorrhage from vessels of smaller calibre ; it is 
especially applicable to hemorrhage from wounds of the vessels of the 
mouth, nostrils, vagina, or rectum. 

Hot Water. — Hot water will be found a very efficient means of con- 
trolling hemorrhage from small vessels, and it may be used in the form 
of a hot antiseptic solution. It is of especial value in capillary or 
parenchymatous hemorrhage ; it is employed in the form of a douche 
or by means of sponges dipped in the hot solution and packed into the 
wound. Injection of hot water is the most satisfactory means of con- 
trolling uterine hemorrhage. 

Styptics. — These agents are sometimes employed to control capillary 



GENERAL TREATMENT OF HEMORRHAGE. 131 

bleeding or hemorrhage from small vessels, but, although their use is 
found satisfactory as regards the control of the bleeding, they have the 
disadvantage of interfering with the primary union in wounds, and since 
the value of asepsis in wound-treatment has been demonstrated they are 
now very seldom employed. The most valuable styptics which are used 
are alcohol, alum, oil of turpentine, perchloride of iron, persulphate of 
iron (or Monsel's solution), acetic acid, or vinegar. 

Pressure. — For the permanent control of arterial hemorrhage pressure 
may be applied directly to the bleeding point or surface by means of a 
compress of antiseptic or sterilized gauze or by strips of gauze packed 
into the cavity from whose surface the bleeding arises. 

Compresses are used with the best results where the proximity of a 
bone gives a firm substance upon which the vessel may be compressed, 
as is the case in the vessels of the scalp. Pressure applied by means of 
packing with strips of gauze will be found most efficient in controlling 
hemorrhage from cavities such as the nose, vagina, or rectum, and in 
the cavities resulting from the removal of necrosed or carious bone. 
Pressure may be indirectly applied by flexing the proximal joint over 
a compress or by firm bandaging of the limb. In controlling bleeding 
from a divided artery in a bony cavity, such as the inferior dental canal, 
a piece of catgut ligature may be forced into the canal, and it will con- 
trol the bleeding in a most satisfactory manner. 

Halsted has recently introduced the use of a material known as gut- 
wool, which is prepared from the submucosa from which catgut is made ; 
this is moistened with alcohol, and cut into fine shreds. The wool 
is preserved in an alcoholic solution of corrosive sublimate, 1 : 1000, 
and is used for stopping excessive hemorrhage from bone, a small quan- 
tity being pressed into the cavity or opening in the bone from which the 
bleeding arises. 

The troublesome hemorrhage sometimes occurring after the removal 
of a tooth may be controlled by packing the alveolar cavity with a strip 
of sterilized gauze or by introducing a wedge-shaped piece of cork into 
the cavity and holding it in place by fastening the jaws together by 
means of a bandage. 

Cauterization. — The use of cauterization by means of a hot iron is a 
satisfactory manner of arresting hemorrhage. Care should be taken to 
have the iron only of a dull-red or black heat, as the result desired is not 
the destruction of the tissues, but the coagulating effect of heat upon 
them. The form of cautery-iron employed will depend upon the posi- 
tion of the vessel. Paquelin's cautery is a very satisfactory apparatus 
to use for the control of hemorrhage. 

Control of arterial hemorrhage by cauterization is often resorted to 
in operations upon the jaws and in the removal of tumors from the 
mouth or pharynx, or of the tonsils ; it is also frequently employed to 
control hemorrhage in operations upon the uterus and the rectum, and 
also that resulting from the removal of abdominal tumors where the 
application of a ligature is difficult and often impossible. 

Torsion. — This method of controlling arterial hemorrhage consists in 
seizing the end of the artery, drawing it slightly out of its sheath, and 
twisting it : it may be accomplished by a single pair of forceps or by 
two pairs of forceps. In the latter method the artery is held by one 



132 



MINOR SURGERY. 



Fig. 165. 



pair of forceps and twisted by the second pair. Torsion of arteries in 
accidental wounds is quite common, and in many cases controls the 
hemorrhage until surgical aid is rendered. The 
femoral artery in Scarpa's triangle has been com- 
pletely controlled in this manner in the case of 
an avulsion of the thigh from railway injury. 
In vessels of moderate size it may be practised 
with one pair of forceps, and the ordinary double- 

FiG. 166. 




Double-spring artery forceps. 

spring artery forceps (Fig. 166) or haemostatic for- 
ceps will be found satisfactory for such cases. In 
larger arteries two forceps should be employed, 
or some of the numerous forms of torsion forceps 
(Fig. 165) which have been devised for this pur- 
pose. 

Ligation. — The use of the ligature is by far 
the most generally employed method of control- 
ling arterial hemorrhage. The materials used for 
ligatures are silk, hemp thread, catgut, horse- 
hair, iron or silver wire. Catgut or silk is the 
material most generally employed. The vessel is 
seized with a pair of artery or haemostatic forceps 
or a tenaculum, and drawn out of its sheath, and 
a ligature of prepared catgut is thrown around 
it and secured by a surgeon's knot or by a reef 
knot and surgeon's knot combined, and when 
firmly tied the ends of the ligature are cut short 



Fig. 167. 




Hewson's torsion forceps. 



Aneurism needle armed with ligature. 



in the wound. Silk ligatures which have been rendered aseptic are 
applied in the same manner, and the ends may be cut short in the 
wound. 

When ligatures are applied to vessels in their continuity they may 
be threaded into an eyed probe or aneurism needle (Fig. 1 67), and carried 
around the vessel and secured. A convenient method of applying a 
ligature to a bleeding point in a deep wound or to a vessel in tissues 
which are of such a nature as not to permit of the isolation of the vessel. 



GENERAL TREATMENT OF HEMORRHAGE. 



133 



Fig. 168. 




Artery occluded by suture (Esmarch). 

way, but the external coat was 



is to use a curved needle threaded with a catgut ligature, which is passed 
deeply into the tissues near the vessel and brought out at the opposite 
side ; the ligature thus placed is then 
firmly tied and the ends are cut short 
in the wound (Fig. 168). 

Constriction or Crushing of Arteries 
for the Arrest of Hemorrhage. — This 
procedure has been adopted for the clos- 
ure of arteries without the use of liga- 
tures or other foreign substances to be 
left in the wound. It was employed by 
the use of an instrument known as the 
artery constrictor, Avhich grasped the 
artery and constricted it in such a way 
that the inner and middle coats g 
preserved intact. 

Arteriversion. — This method of controlling hemorrhage consists in 
constricting the mouths of arteries divided in amputations by turning 
over the cut ends with a little instrument called an arteriverter : with 
this instrument the ends of the divided arteries may be retroverted, and 
the cut extremity of the artery is reinforced by the duplicature of its 
walls, thus surrounding its open mouth with such a quantity of arterial 
nmscular and elastic fibres as to effectually close it against the impulse 
of the heart's action. This procedure has been practised in a few cases, 
but has never come into general use. 

Acupressure. — In this method of controlling arterial hemorrhage a 
needle or pin is used which is thrust through the tissues in such a way 
as to compress the artery. There are a number of methods of using the 
needle or pin. 

First Method of Acupressure. — In this method the surgeon places 
a finger of his left hand upon the mouth of the bleeding vessel, and with 
his right hand introduces the needle from the cutaneous surface, and 
passes it through the thickness of the flap until its point projects for a 
couple of lines or so from the surface of the wound a little to the right 
side of the tube of the vessel. By forcibly inclining the head of the 
needle toward the right he brings the projecting portion of its point 
firmly down on the side of the vessel, and after seeing that it occludes 



Fig. 169. 



Fig. 170. 





Acupressure— first method : raw 
surface (Erichsen). 



Acupressure— first method : cutaneous 
surface (Erichsen). 



the artery he makes it re-enter the flesh as near as possible to the left 
side of the wound, and pushes the needle through the flesh till its point 
comes out again at the cutaneous surface (Figs. 169, 170). 



134 



MINOR SUBGERY. 



Second Method of Acupressure. — A straight needle threaded with a 
short piece of iron or silver wire, for the purpose of afterward retracting 
and removing it, is passed down through the soft parts a little to one 
side of the vessel ; its point is then raised up and passed over the artery, 
and is then turned down again and thrust into the soft tissues on the 
other side of the vessel (Fig. 171). 

Fig. 172. 





Acupressure — second method 
(Erichsen). 



Acupressure — ^third method 
(Erichsen). 



Third Method of Acupressure, or Filo-pressure. — In this method the 
point of the needle is passed into the tissues a few lines to one side of 
the vessel, then passed under it, and afterward pushed on, so that the 
point again emerges a few lines beyond the vessel. A loop of wire is 
next passed over the point of the needle, and then, after being carried 
over the vessel and passed around the opposite end of the needle, it is 
drawn sufficiently tight to close the vessel, and the ends of the wire are 
secured by making a twist around the stem of the needle (Fig. 172). 

Fourth Method of Acupressure. — This method is identical with the 
third method, except that a long pin is used in place of the needle ; the 
head of the pin remains outside of the wound. 

Fifth Method of Acupressure, or Acutorsion. — This method consists in 
passing a pin or needle through the soft tissues close to the artery, and 

Fig. 173. 




Acupressure— fifth method {Erichsen). 

by giving the pin a quarter or half rotation twisting the vessel upon 
itself, and fixing the pin by thrusting its point deeply into the tissues 
beyond (Fig. 173). 

Treatment of Venous Hemorrhage. 
Bleeding from small veins often stops spontaneously unless there is 
some pressure upon the wounded veins upon the cardiac side of the 
wound. _ It is, however, very satisfactorily controlled by position, or by 
the application of a compress and bandage, or by the use of a ligature : 
if the divided vein be a large one, it is well to "secure both ends of the 



TREATMENT OF SECONDARY HEMORRHAGE. 135 

vein by ligatures. The free bleeding arising from ruptured varicose 
veins of the leg is easily controlled by a compress and bandage, while 
hemorrhage from the larger veins, such as the jugular, should be con- 
trolled by the application of ligatures as in the case of wounded arteries. 
The application of the lateral ligatures to small wounds of veins of large 
size, such as the femoral, jugular, or subclavian, or to wounds of the 
venous sinuses, has been recommended and employed with good results. 
It consists in pinching up the wall of the vein so as to include the orifice 
of the wound and thromng a delicate silk or catgut ligature around it 
and tying it firmly. The use of the actual cautery may also be required 
for the control of venous hemorrhage in positions in which its arrest by 
pressure or the ligature is not feasible. 

Treatment of Oapillaey or Parenchymatous Hemorrhage. 

Capillary or parenchymatous hemorrhage is usually arrested spon- 
taneously by the exposure of the surface of the wound to the air, but 
it is often so profuse that its arrest becomes a matter of importance. 
To control this form of bleeding, pressure may be applied to the sur- 
face for a short time, and if this fails to arrest it, sponging the sur- 
face with dilute alcohol will sometimes prove satisfactory ; but the best 
application to arrest hemorrhage of this nature is hot sterilized water or 
hot water, which may be used in the form of a hot bichloride solution. 
Acetic acid and vinegar are also sometimes employed for the same pur- 
pose. In cases where the means mentioned above fail to control the 
bleeding it may be necessary to pack the wound with strips of antiseptic 
gauze : this dressing is most serviceable when the hemorrhage comes 
from cavities, such as results from the removal of tumors or excision of 
joints ; and for the control of bleeding following the removal of necrosed 
or carious bone packing the cavity resulting is the method very generally 
employed. To control hemorrhage from mucous cavities, such as the nose, 
rectum, and vagina, this method of treatment is sometimes resorted to. 

Treatment of Secondary Hemorrhage. 

Secondary hemorrhage following the use of the ligature or other means 
of controlling bleeding is, since the adoption of the aseptic method of 
wound-treatment, a much less frequent complication of \TOunds. The 
treatment of this complication is both constitutional and local. The 
•constitutional treatment consists in the use of those remedies which were 
mentioned as serviceable in primary hemorrhage, and the drugs on which 
the most reliance is to be placed are opium and ergot. The local treat- 
ment of this form of hemorrhage consists in the use of the various means 
of controlling hemorrhage which have been mentioned before, such as 
the ligature, hot water, pressure, or the actual cautery. If possible, it is 
well to secure the vessel from which the bleeding arises in the wound. 
If for any reason this cannot be done, the main artery should be ligated 
at the point of election above the wound if the hemorrhage be arterial. 

Rules foe Ligating Wounded Arteries. 

In case of primary hemorrhage the bleeding artery should be sought 
for and secured by a ligature. In applying a ligature to a wounded 



136 MINOR SURGERY. 

artery the surgeon should cut directly down upon it at the point from 
which it bleeds, and secure it in the wound. This rule holds good for 
both primary and secondary hemorrhage. 

Two ligatures should be applied — one to each end of the artery if it 
be completely divided, and one on each side of the wound if the latter 
has not completely severed the coats of the artery. This procedure is 
adopted for the reason that the arterial anastomosis is so free that the 
proximal ligature will not always, even temporarily, arrest the bleeding ; 
and if it does accomplish this object at the time, after the collateral cir- 
culation is established bleeding is apt to occur from the distal extremity 
of the divided vessel. If the coats of the artery are not completely 
severed, their division should be completed either before or after the 
application of the proximal and distal ligatures, thereby favoring the 
contraction and retraction of the ends of the divided vessel. 



PLASTIC SURGERY. 

By GEORGE R. FOWLER, M. D. 



Injuries and Inflammations of the Facial Region. 

Wounds. — Owing to the vascularity of the parts, wounds of the 
face bleed freely. With the exception of some of the larger branches 
of the facial artery, however, the application of a ligature is seldom 
required. This same vascularity also explains the almost invariable 
occurrence of healing by first intention of wounds in this region. Even 
in tissues considerably lacerated and contused, sloughing is a rare cir- 
cumstance. Nature's efforts are frequently successful in filling up 
defects, hence plastic procedures are best deferred until complete cica- 
trization takes place. 

Bums. — Burns from hot water, caustic liquids, and chemical sub- 
stances driven against the face in laboratory accidents are usually deeper 
than at first appear, and frequently involve an unfavorable prognosis so 
far as the cosmetic effect and function of the parts are concerned. In 
the case of the lower lip the saliva trickles away and the formation of 
labial sounds is interfered with. Ectropion of the lower eyelid permits 
the tears to flow over the face, and the globe of the eye suffers in conse- 
quence. Extensive formation of cicatricial tissue at the lateral aspects 
of the cheeks embarrasses the movements of the lower jaw. Operative 
interference is here demanded. 

Gunpowder Accidents. — The presence of powder-grains in the skin 
of the face involves considerable disfigurement. When recent, the 
greater portion of them can be removed by vigorously scrubbing the 
face, under an anaesthetic, by means of a coarse and stiff hand-brush 
(Richardson). A stiff cataract needle applied to each powder-grain if 
the case is not seen until late will remove these in the course of time, 
although many sittings are required. According to Hebra, the prolonged 
application of a 1 per cent, solution of mercuric chloride is said to facil- 
itate the extraction. 

Simultaneous Wound of Skin and Mucous Membrane. — When 
both skiu and mucous membrane are wounded at the same time, sep- 
arate suture of the divided structures is required. This is particularly 
true of the eyelids. Perforating wounds of the oral cavity, if permitted 
to cicatrize, leave fistulous openings, through which liquids that are 
taken into the mouth escape, as well as the mucus and saliva. Stenson's 
duct may be involved in the injury, and the parotid secretion poured 
upon the outside of the face. 

Traumatic Inflammation. — The extension of septic processes in the 
facial region are of rather infrequent occurrence, although the extensive 
vascularity of the soft parts would tend to favor such extension. This 
comparative immunity from spreading inflammatory conditions is mainly 

137 



138 PLASTIC SURGERY. 

due to the peculiar arrangement of the subcutaneous connective tissue, 
which passes directly at right angles to the surface to embrace the sub- 
cutaneous muscles. Although wounds in the neighborhood of these 
muscles gape widely, the peculiar arrangement of the connective-tissue 
fibres prevents propagation of septic inflammatory processes. In other 
parts, however — as, for instance, in the eyelids — the fibres of the con- 
nective tissue are arranged parallel to the fibres of the orbicularis palpe- 
brarum, and phlegmonous inflammation is more apt to occur. Destruction 
of tissue here may give rise to cicatricial shortening of the integumentary 
surface of the lid, and consequent ectropion. Extension of the septic 
processes through the medium of the palpebral fascia and along the 
muscles of the globe or sheaths of the nerves into the mass of fat behind 
the globe inself, and thence through the superior or inferior orbital fissure 
to the brain, may occur. 

A characteristic symptom of septic inflammation about the face is 
cedematous swelling of the involved parts. This is due, in part, to 
venous and lymphatic congestion, and in part to serous infiltration. 
Erysipelas infection likewise produces oedema. The occurrence of ery- 
sipelas in the face may lead to an extension to the scalp, and to the 
peculiar dangers which arise from the presence of infection in that 
region. Septic thrombi in the facial and orbital veins may give rise to 
serious metastatic pyaemia. 

Although the facial region, therefore, is not particularly prone to 
inflammatory septic processes, yet in localities where it does occur serious 
results may follow. To add to the difSculties, the presence of the nares 
and mouth somewhat embarrasses the efi&cient application of antiseptic 
dressings. The application of collodion mixed with subiodide of bis- 
muth or iodoform (Kuester), pencilled over the wound-edges along the 
line of coaptation, is here very useful. 

Non-traumatic Inflammation. — Eczematous conditions of the skin of 
the face in children are of interest to the surgeon principally from the 
lymphatic glandular involvement near the angle of the jaw which is apt 
to follow. 

In addition to ordinary bacterial infection, the integument of the face 
is liable, through the open follicles, to invasion of the so-called thread 
fungi. The special varieties of inflammation caused by these ectophytes, 
such as favus, sycosis or mentagra, blepharadenitis, or inflammation at 
the ciliary margin, belong to the domain of dermatology. 

Facial Erysipelas. — This disease was formerly relegated to the 
domain of internal medicine, under the belief that it was an idiopathic 
affection. The disease, however, depends upon the presence of a specific 
germ which finds its entrance into the depths of the skin probably 
through some slight fissure, excoriation, the site of an acne pustulata, or 
the follicular openings upon the nose, which are unusually large. Its 
course is similar to that observed in the case of wounds, and the same 
treatment is applicable. 

Plastic Surgery. 

Plastic operations are resorted to for the purpose of restoring in an 
artificial manner lost portions of the body by means of living tissues. 



PLASTIC SUBGEBT. 139 

The skin forms the most essential material for plastic operative pro- 
cedures upon the surface of the body. This structure is particularly 
adapted for this purpose by reason of its exceedingly rich blood-supply 
and numerous capillaries. 

Heteroplastic operations consist of replacing defects by means of tis- 
sue taken from sources other than the individual in whom the defect 
occurs. In this are to be included transplantation from one individual 
to another, as well as from a lower animal to man. Investigations as to 
the practicability of the latter are still in progress, and the attempts thus 
far made are sufficiently encouraging in their results to justify a still 
further trial of the method. 

Autoplastic operations consist in replacing the defect by means of 
tissue taken from the same individual. 

The indications for plastic operations consist of defects resulting 
from — (1) congenital cleft-formations, such, for instance, as hare-lip, 
cleft-cheek, fissures of the hard and soft palate, extrophy of the bladder, 
€tc. ; (2) from injuries ; (3) from thermic and chemical destructive action ; 
(4) from diseased conditions, such as carcinoma, lupus, and syphilitic and 
tubercular ulcerative action ; (5) from the removal of benign tumors, 
angiomata, etc. ; (6) from cicatricial displacement or distortion of parts 
resulting from inflammatory cicatrizing processes. In the latter class 
of cases plastic operations are demanded not so much because of loss of 
tsubstance as from disturbances of shape and function of parts. 

The indications may be further divided into those of a cosmetic and 
those of afunctional character. In the former the patient's own choice 
nsually governs, to a great extent, the surgeon's decision as to the advisa- 
bility of operating ; in the latter he will be in a position to directly 
advise the patient as to the best course to be pursued. There are also 
instances in which both cosmetic and functional considerations enter into 
the question — as, for instance, in the case of ectropion of the eyelid. 

The time for performing p>lastic operations will depend upon the cha- 
racter of the case, and particularly upon the cause of the defect. In the 
•case of injuries the plastic replacement should be attempted at once, and 
by means of the part itself which has been removed. Portions of the 
nose, fingers, tongue, etc. should be replaced immediately and sutured 
in position. Where the parts have been considerably crushed or other- 
wise destroyed, however, replacement cannot be successfully accom- 
plished. Cases are on record in which attempts at immediate suturing in 
position of parts cleanly cut off have been successful even after an hour 
or more has elapsed since the reception of the injury.' 

The time for operative interference in congenital defects also differs, 
the decision of the operator being guided by the location of the defect, 
its interference with important functions, the strength of the child, etc. 
(Vide infra.) 

When plastic operations are applied for the correction of defects 
resulting from ulcerative processes arising from such destructive diseases 
as syphilis, tuberculosis, etc., the local focus must at first be healed, both 
local and general measures being employed for that purpose. In cases 

' Finney reports having successfully replaced the ends of the middle and ring fingers 
seven hours after they had been cut off (Johns Hopkins Hospital Builetin, Baltimore, 
Oct. and Nov., 1892). 



140 



PLASTIC SUBOEBY. 



of carcinomatous and other tumors, if these can be thoroughly extirpated 
and healthy parts reached, the plastic operation best adapted to the 
conditions present may be at once proceeded with while the patient is 
still under the anaesthetic. 



General Methods of Plastic Operations. 

Two essential methods are employed. The first consists of utilization 
of tissues from the immediate neighborhood ; the second, of their trans- 
plantation from a distant part. The first method may be again divided 

Fig. 174. 






s 


/ 

\ 

\ 


B . , 

I 

L 

9 
B 


B 
L 

B 



Relaxing incisions. 



into those in which the tissues used to replace the defect are brought into 
position by sliding or lateral displacement, and those in which flap-forma- 
tion and twisting of the pedicle are distinguishing features. 



Fig. 175. 



j< li I I II II liiiiiiiiiiNi till III uuilini 



iiBiiiwiiillUiliililililfiiiyiii^ 



Closing a rectangular-shaped gap. 



Replacement by means of lateral displacement may sometimes be 
accomplished without the introduction of new tissue, on account of the 



Fig. 176. 




r 


\ 


liillLiiilliL 


< 


iiiiiiiiiiii 

k 


!■ 


r 


lii 






(' 







Dleffenbach's method of closing a triangular-shaped defect. 



yielding character of the tissues. This may be aided by loosening the 
skin structures by means of more or less extensive dissection along the 
plane of subcutaneous connective-tissue space, or the employment of 
relaxing incisions (Fig. 174), made parallel to the intended line of 



GENERAL METHODS. 



141 



sutures, or both. These latter are permitted to heal by granulation. A 
method of closing a rectangular-shaped defect is shown in Fig. 175. 
Dieifenbach's procedure for closing a triangular-shaped defect is shown in 
Fig. 176. The method of Dieffenbach was still further improved by Bruns. 
Bruns' Method. — Bruns' operation for the closure of large trian- 
gular defects is carried out as follows : Two lateral incisions are made 
(d a, b e, Fig. 177), the edges of the defect, b c, a c, freshened, and the 




Fig. 178. 



Bruns' method of closing a large triangular gap. 

flaps, dae, eb o, detached and brought together, the margins, b e and a c, 
uniting. The redundant tissue which is present at the angles, a, b, being 
removed, two triangular-shaped raw surfaces, df a, eg b, are left, which 
are closed finally. 

Lettenneur's Method of Closing a Quadrilateral Gap. — An incision 
(6 e, Fig. 1 78) is made along the lower border of the defect, then down- 
ward to /, and finally, in a curved direction, to g. The 
space between g and 6 represents the pedicle of the 
flap. The latter is dissected from its attachments and 
displaced in an upward direction, the margin e f being 
sutured to a d. 

Flap-formation with torsion is more frequently em- 
ployed than the foregoing. The advantages of this 
method consist in — (1) its almost universal applicabil- 
ity ; (2) the flaps can be more accurately adapted to 
the defect ; (3) tissues free from disease can be selected 
for the purposes of repair ; (4) by proper care in 
placing the pedicle nutrition of the parts may be 
more certainly assured. When the transplanted por- 
tion is taken from a distant part, the latter is approx- 
imated to the place of defect ; under these circumstances torsion of the 
pedicle may or may not be employed. (See operation of Tagliacozza, 
p. 182.) 

In order to secure the nutrition of the transplanted portions certain 
precautions are necessary. Death of these is less apt to follow the method 
of sliding than any other. In flap operations with torsion the flap must 
be sufficiently narrow, else the twist which it receives may result in 
undue pressure upon, and hence narrowing of, the vessels of supply. 
Among the precautions to be observed, the most important are the fol- 
lowing : (1) The pedicle is to be located in a region from which a free 




^\ 



Lettenneur's operation. 
The flap represented 
by the dotted lines 
should be proportion- 
ately larger. 



142 PLASTIC SUBGEEY. 

supply of vessels pass to the portion to be transplanted ; (2) the forma- 
tion of the flap must be accomplished with the greatest care, the edge of 
the scalpel being directed away from the skin, particularly when dissects 
ing near the pedicle itself, in order to avoid injury to the latter ; (3) an 
accurate isolation of the pedicle is necessary in order to permit of tor- 
sion without folding ; (4) the pedicle must be sufficiently long to permit 
of an easy twist. The latter is to be further provided for by extending 
the incision which marks one boundary of the pedicle somewhat farther 
than the other, so that there is a long and a short edge to the latter, the 
long edge representing the margin or boundary /rom which the twist is 
turned. 

In addition to these precautions, care must be taken that the raw 
surface of the flap fits closely upon the properly-prepared surface of the 
defect, and that the edges of the former are accurately sutured to those 
of the latter. All cicatricial tissue, if this is intended to be replaced by 
the transplanted portion, must be dissected entirely away, in order to 
obtain a normally vascularized surface for the reception of the flap. 
The chances of success will be verj' much enhanced by the employment 
of aseptic measures. 

Plastic operations in the facial region are, as a rule, more successful 
than elsewhere, for the reason that here there is an exceptionally rich 
supply of arterial and capillary vessels. The tissues of the scrotum 
oifer similar advantages. In regions where the vessels are less plentiful 
it is sometimes of advantage to loosen the flaps from the subcutaneous 
connective tissue, allowing them to be nourished by a pedicle at either 
end, packing beneath with gauze dressing material or oil-silk protective, 
and completing the operation at the end of a week, when a profuse 
granulating surface has been obtained. The newly-formed vessels in- 
crease the nutrition of the flap. One of the pedicles is severed, and the 
edges of the flap and defect freshened when approximation is effected. 
This method is called transplantation of a granulating flap. It is par- 
ticularly useful in the operative treatment of extrophy of the bladder. 

Elastic and cicatricial shrinhing of the flap must be taken into 
account in planning plastic operations. The first named takes place at 
once, and amounts to about one-third of the entire area of the flap. It 
must be compensated for by an increase in the dimensions of the trans- 
planted portion over the size of the defect. The second is to be guarded 
against by bringing the surfaces as accurately into apposition as possible, 
thereby securing primary union, rather than filling of an intervening 
space by granulation. In replacing a nose the newly-formed part must 
at first be largely in excess of the original nose, in order to allow for the 
very considerable shrinkage which inevitably occurs in the course of a 
few months. 

Secondary shrinkage of the flap is prevented to a great extent by 
reinforcing the latter by means of the cicatricial tissues about the defect. 
For instance, in the case of a defect of the anterior and inferior portion 
of the nose the skin at the root of the organ is circumscribed by a horse- 
shoe-shaped incision, loosened and turned downward, its raw surface 
corresponding to that of the flap taken from the forehead. 

Under some circumstances the underlying periosteum may be em- 
ployed as a portion of the transplanted structures. In the operation of 



OENEBAL METHODS. 143 

uranoplasty this is imperative, and also where cicatricial tissue must be 
utilized, the vessels between the cicatrix and periosteum being carried 
along with the flap. 

The cireulation in the flap may be retarded by the formation of 
coagula. It is better to have a rather pale than a bluish or congested 
flap, and in order to prevent the latter it is advisable to permit the flap 
to empty itself of blood before suturing it in position. In the case of a 
pale flap the normal color is restored in the course of twenty-four hours 
if all goes well. 

At first the sensation in the transplanted portion is referred to the 
part from which the flap was taken. In the course of time, however, 
restoration of normal conduction of sensation occurs. 

Complete sepjaration and transplantation of larger flaps dissected 
from the subcutaneous connective tissue are now rarely practised, on 
account of the frequent failure of nutrition and death of the flap. The 
method is largely replaced by those next to be discussed. 

Reverdin's Method. — In 1870, Reverdin introduced the method which 
bears his name for the healing in of larger defects arising from burning, 
injuries, sloughing phagedena, and varicose ulcers. It consists of the 
implantation of small flat portions of epidermis, which are completely 
separated and which form islands upon the granulating surface of the 
defect. These soon become surrounded by a zone of proliferating epi- 
thelium. Although the transplanted epidermis is not very stable, the 
outermost layer being cast off and giving every appearance of failure, 
yet sufiicient epithelial structure remains from which further prolif- 
eration occurs. In this manner the entire surface is finally covered. 
Small pieces for transplantation only should be used. Those of more 
than one, or at the most two, centimetres are apt to be followed by 
failure. The transplanted portions should be of skin only, and in order 
to better close the defect from which these are taken, when sufficiently 
large to require coaptation of their edges, they should be elliptical- 
shaped. Minute portions of skin when transplanted in this manner are 
sometimes employed, the process being called shin-grafting. 

Thiersch's Method. — This consists in curetting or scraping away the 
granulating surface down to the solid base of the ulcer or other defect, 
and then implanting thereon strips consisting of the epidermal layer 
only. In this method the strips are shaved off by means of a razor, 
the part from which the strips are removed being made tense by grasp- 
ing the circumference of the part or by means of specially-devised appa- 
ratus. The razor is laid flatwise upon the surface, and by to-and-fro or 
sawing movements a strip is obtained by splitting the skin in a direction 
parallel with its surface. These strips are from two to four centimetres 
wide and of varying lengths, according to the requirements of the case. 
To facilitate the removal of the strips it is necessary to render the skin 
tense at the point of proposed removal. The skin-stretching hooks of 
Dr. Charles McBurney are useful for this purpose (Fig. 179). Their 
method of application is shown in Fig. 180. A number of strips may 
be necessary to fill in the defect. The outer surface of the arm or thigh 
is usually selected from which to remove the strips. 

Dressings, etc. — Skin-grafting should be accompanied by aseptic pre- 
cautions ; antiseptic fluids which coagulate the albuminous elements of 



144 



PLASTIC 8UBGEBY. 



the tissues of the parts should not be employed. A normal salt-solution 
(A P^'^ cent.) answers every purpose. Gauze dressings, as well as sponge 
materials, used at the operation should be wrung out of the same. After 
the strips are placed in position the site of the operation should be care- 



FlG. 179. 




Dr. McBurney'a skin-stretching hooks. 
Fig. 180. 




Method of applying McBurney's hooks. 

fully covered by narrow strips of oil-silk protective, arranged as in 
basket-strapping. Over this is placed a liberal supply of aseptic gauze, 
and the whole covered with sterilized non-absorbent cotton and secured 
in place by a roller bandage. The first re-dressing is done on the third 
or fourth day. Care should be taken not to disturb the transplanted 
portions of tissue. 

Cicatricial Keloid following Thiersch's Method. — The secondary form- 
ation of cicatricial tissue beneath and between skin-grafts, resembling 
false keloid (Murray) ^ and giving rise to secondary contraction, is some- 
times observed. This formation may take place when the grafting at 
first seems to be successful in every respect. According to McBurney, 
this is due to the too early abandonment of wet dressings, and he advo- 
cates that these be continued for two weeks following the operation. 
It is probable that the false or cicatricial keloid formation depends upon 
the causes which produce it under other circumstances. 

Oicatrieial Deformities following Burns. — The most important of 

' New York Medical Journal, Feb. 4, 1893. 



CHEILOPLASTY. 145 

these are those of the face, neck, and upper extremities. The various 
methods of treatment, consisting of screw apparatus, elastic tension, 
weights, etc., as well as forcible rupture and total excision, even when 
followed by skin-grafting, save in cases of the simplest character, have 
been followed by only indifferent results. The various methods by flap 
operations have met with much better success. 

Oroft's Operation for Deforming Cicatrices. — This consists essentially 
in raising a flap of healthy skin adjoining the cicatrix, leaving it attached 
at both ends, but loosening it entirely in the middle, passing a strip of 
oil-silk protective beneath to prevent it from uniting to the subjacent 
tissue from which it has been elevated, and waiting until the process of 
granulation has been well established before proceeding further. When 
a granulating surface has been secured upon the raw surface of the 
strap-shaped flap, this is severed at one end, and the gap made by the 
division of the cicatrix and reduction of the deformity filled therewith. 

The flap should be taken from structures well supplied with blood, 
and so placed as to be brought readily into its new position. Care 
should be taken to have the strap of sufficient length, and to prevent it 
from becoming unduly shortened prior to its transplantation by gran- 
ulation tissue springing up in its angles during the two or three weeks 
that intervene between the two stages of the operation. The edges 
of the wound from which the strap was raised should be sutured 
together at once as far as possible. At the centre one or two sutures 
securing the parts to the muscles and fascia beneath will assist in pre- 
venting tension upon the sutures. The parts must be kept at rest, and 
the application of fixation apparatus will help to maintain this, particu- 
larly in young children. 

At the second stage of the operation the contracting cicatricial struc- 
tures are divided, the deformity reduced, and one end of the flap severed. 
The end retained as a pedicle should be that at which the vessels enter. 
The gap left by dividing the scar is to form a bed upon which the flap 
is to be placed. While this may be fashioned somewhat to correspond 
to the shape and size of the flap, yet an accurate adjustment of these is 
not possible nor even necessary. The flap, after being freed at one end, 
is trimmed, and about one-half of its raw surface toward the free end 
deprived of granulations by paring, in order to secure primary union 
between this and the fresh wound at the gap. 

Primary union between the free end of the flap at the fresh wound 
does not always occur, in which case the flap must be maintained in 
position by strapping. Success will frequently follow even in these 
unpromising cases. When the implant has become firmly united it 
gradually flattens out and becomes broader. At least six months will 
elapse before the extent of the improvement can be estimated. 

Cheiloplasty. 

Estlander's Operation. — In cases in which it may be deemed desirable 
to replace the lost margin of the lower lip at once where the loss of 
substance is partial, is limited to one side, and the defect extends down- 
ward upon the chin, this method may be employed (Figs. 181, 182). A 
flap, the base of which is formed at the upper lip, is taken from the 

Vol. II.— 10 



146 



PLASTIC SUBGEBY. 



cheek and carried down to assist in filling the gap. If tare is taken in 
shaping the flap, it will contain the superior coronary artery, which will 
aid in maintaining its nutrition. 



Fig. 181. 



Fig. 182. 




A B 

Estlander's eheiloplastic operation. 



LangenbecFs Operation. — The incisions are a prolongation of the 
lower horizontal margin of the defect in either direction, and are curved 
around the angles of the mouth so as to extend into the upper lip. As 
much of the median segment of the upper lip as possible must be pre- 
served consistently with the extent of defect to be closed, in order that 



Fig. 183. 



Fig. 184. 





A B 

Restoration of the lower lip ; Langenbeek's operation (after Lobker). 

the communication between the coronary vessels and the arteries of the 
septum may not be disturbed. The portions of^the lip thus included are 
drawn together toward the symphysis of the lower jaw, and there united 
by sutures, care being taken in finally closing the wound to fix the new 



Fig. 185. 



Fig. 186. 




A ' B 

Lines of incision. Appearance after suturing. 

Langenbeek's operation for restoration of the lower lip (Huctcr). 

angles of the mouth in a position to preserve the normal outlines' (Figs. 
183, 184). 

This operation is adapted for cases in which the loss of substance is 
limited to the free portions of the lip. In cases in which it can be car- 




PLASTIC OPERATIONS UPON THE UPPER LIP, ETC. 147 

ried out it possesses, in males, the advantage that a beard can be grown 
in such a manner as to hide the line of union. 

Method by Single Flap from the Chin. — When the defect to be filled 
is so great that the above method is not applicable on account of the 
diminution of the oral aperture which it involves, Langenbeck operated 
as follows : A flap is cut from the chin, with its base or pedicle directed 
upward and outward {A, Fig. 185). The edges of the defect are 
freshened, the flap detached and displaced upward, the triangular piece 
of skin, DR, serving to support the latter. 

The tiyme- Buchanan Method. — Two flaps are secured from the tissues 
of the chin. The edges of the defect are 
prolonged downward by two incisions (a Fig. 187. 

b c', a' b 0, Fig. 187), the flap being com- 
pleted by the incisions c d, o' d'. The flaps 
thus marked out are dissected from their 
attachments beneath, and turned upward 
in such a manner as to be united by sutures 
along the line b e, b a' . No effort should 
be made to close the triangular gaps, lest 
the margin of the new lip be brought to 
too low a level ; this should heal by granu- 
lation. In this operation the point of the ^^'^^-^''t^^f^^X^t^4"°"^' 
the chin is preserved. 

Bruns' Operation. — Special operative procedures are to be instituted 
in cases in which the disease is more extensively distributed. When 
the entire lower lip is involved, Bruns' operation, in which the defect is 
supplied from the cheeks, will replace the lost tissue (Figs. 188, 189). 

Fig. 188. Fig. 189. 






Bruns' operation for restoration of the lower lip 

As time passes, in this as in all plastic operations in this region in 
which the normal elastic lip is substituted by a flap with a cicatricial 
edge, the latter contracts, is drawn tightly against the lower jaw, and 
saliva trickles over the edge in spite of every effort to prevent it. 

Plastic Operations upon the Upper Lip for Non-congenital 

Defects. 

These are rarely required. In small defects operations based upon 
some of the plans already described for the lower lip will be found 
useful. Specially-devised procedures may be necessary in certain cases. 

Dieffevhaeh's Operation. — This is employed where the central part 
of the upper lip is deficient and the edge of the defect covered with 





148 



PLASTIC SUBGEBY. 



mucous membrane. Two flaps are marked out by two curved incisions 
which commence at the apex of the defect and are carried around the 
alse of the nose (Fig. 191). These are dissected loose and brought 
together in the median line, the mucous membrane which formed the 
inferior margin of the flap having been preserved to form the free 
border of the restored lip (Figs. 190, 191). 

Fig. 190. Fig. 191. 








Dieflfenbach's'operation for restoration 
of tne upper lip. 



Diefltenbaeh's operation : the sutures 
applied. 



Buck's Operation. — Gurdon Buck operated in a case in which one- 
half of the upper lip and a portion of the cheek had been lost, as fol- 
lows:' The lower lip is divided by a vertical cut (a b, Fig. 192) one 

inch in length at right angles to the 
margin of the lip. A second incision 
{b o), commences at the lower end of the 
first, and is carried forward for about an 
inch and a half parallel with the margin 
of the lower lip. A third incision (c d) 
starts from the termination of the sec- 
ond, and extends obliquely upward for 
about half an inch or not quite to the 
lip. This attachment should not be 
encroached upon too closely, lest the 
nutrition of the flap be interfered with. 

The sound portion of the upper lip 
is now to be dissected freely loose from 
its bony attachments, the edges of the 
defect carefully pared, and the flap from 
the lower lip brought into position and 
secured by suturing it to the freshened 
edge of the upper lip. The gap left by 
the flap is also sutured. 
Serre's Operation. — This operation is intended to restore the angle 
of the mouth which has become distorted by a cicatricial contraction 
or removed in the extirpation of a gnnvth. Three incisions are made. 
The first is horizontally placed ; the second extends from the outer ter- 
mination of the first obliquely downward, marking out a triangular 
space ; the third and fourth form a second but smaller triangle. The 
bases of both triangles meet at the site of the new angle of the mouth 
(Fig. 193). When the gap which results from the removal of the tissues 
thus circumscribed is closed, the appearance shown in Fig. 194 is presented. 
Stomatoplastic Operations. — While cheiloplastic operations aim 
to replace parts lost by injury or disease, stomatoplastic operations are 

' Gontnbutions to Beparative Surgery, 1876. 




Buck's operation for restoration of the 
upper lip. 



CONGENITAL DEFORMITIES OF FACIAL SOFT PARTS. 149 



designed to correct pathological mouth-formation. The indications are 
(1) macrostoma ; (2) microstoma ; (3) ectropion of the lip. 




Fig. 194. 




Serre's operation for restoring the angle of the mouth. 

Macrostoma. — In case of congenitally large mouth the operation of 
freshening the edges of the cleft at the angles of the mouth and uniting 
the same is a simple procedure. There is usually no tension upon the 
parts, and union is rapid and complete. 

Microstoma. — This is seldom congenital. Its most common cause 
is cicatricial contraction of the oral orifice following disease and injury. 
For its correction an incision is made for the necessary distance beyond 
the angle of the mouth, and " hemming " this with the mucous membrane 
from the lining of the cheek, which is loosened for this purpose. In 
order to prevent the incision from granulating together at the angle, 
toward the median line the incision is prolonged in a Y, placed horizon- 
tally at the angle, the mucous membrane of the cheek loosened more 
extensively at this point, and the triangular-shaped flap of mucous mem- 
brane is sewn to the new angle, as in Roser's method for phymosis. 

Rudtorffer's Stomatoplastio Operation. — This consists of perforating 
the cheek at the point where the new angle is to be formed, and passing 
through the opening a metallic wire. When cicatrization of the opening 
is completed the usual incision is made from this point to the already 
existing oral opening, and hemmed with mucous membrane after Dief- 
fenbach's method. The difficulty in obtaining cicatrization of the opening 
through which the wires are passed constitutes the chief objection to this 
method. 

A tendency to recontraction following operations for microstoma may 
be overcome by having the patient wear an oval double-flanged ring, 
made of hard rubber, for an hour or more each day. 

Ectropion of the Lips. — This occurs usually from accidental con- 
traction of the mucous membrane of the lips. It is to be corrected by 
V-shaped excision of the cicatrix and Y-shaped union of the gap, as in 
ectropion of the eyelids. While this operation will correct simple cases, 
in severe forms cheiloplastic procedures are indicated. Separation of the 
labial edges from the cicatricial tissue, raising them to the proper level, 
and filling the resulting gap by a flap with a pedicle will prove successful 
in a certain proportion of cases. 

Congenital Olbpt Deformities of the Facial Soft Parts. 

In the course of foetal development the greater portion of the face is 
formed from the fronto-nasal process or arch. The latter consists of three 



150 



PLASTIC SURGERY. 



plates — the central or mid-frontal, and two lateral or cheek plates. The 
former develops in a downward and forward direction from the middle 
of the base of the skull, forming the nose and a portion of the upper lip. 
The lateral plates are separated from the mid-frontal plate by a furrow 
upon either side, which furrows form the primary nasal pits or fossse. 
The latter are shut off from the rest of the face by the development and 
union of the lateral plates with the mid-frontal plate. The central part 
of the upper lip and the premaxillary bone (see Cleft-palate, page 163) 
are formed by the union of the lateral plates with the mid-frontal process. 
The lower margins of the thin plates form at the same time the upper 
limit of that branchial cleft the persistence of a portion of which forms 
the oral orifice. The presence of cleft deformities is to be attributed to 
a failure of certain processes or arches, formed during foetal development, 
to coalesce and thus close the intervening gap or cleft. Those of the soft 
parts of the facial region consist of defects of the upper lip (hare-lip), 
fissures of the cheek, fissures of the lower lip, and fistulas of the lower 
lip. (For Hare-lip see page 152.) 

Fissure of the Cheek. — This is observed (1) as a vertical cleft ; (2) 
as a horizontal cleft ; (3) as an angular fissure. In isolated cases the 
edges of the cleft appear as scar tissue. In the majority of instances 
of the deformity the angle of the cleft is attached by a connecting 
bridge or frsenum to the gums ; exceptionally it is attached to the hard 
palate. Fissures of the cheek are sometimes present upon both sides, 
and occur simultaneously with other cleft deformities, as well as with 
congenital hypertrophy of the tongue (maoroglossa). 

Vertical fissure arises from defective union of the two lateral plates 
to the mid-frontal process. In extreme examples of the deformity the 
fissure reaches to the lower eyelid (coloboma palpebrce), the mucous mem- 
brane of the edges of the cleft joining that of the enlarged oral orifice. 



Fig. 195. 



Fig. 196. 





Vertical fissure of the cheek (after 
Fergusson). 



Horizontal fissure of the cheek (after 
Fergusson) : an integumentary 
appendix is seen at A. 



as well as the conjunctiva. The cleft may continue through the upper 
eyelid to the forehead (Hasselmann) or it may be connected with the 
nasal cavity (Verneuil). 



CONGENITAL BEFOBMITIES OF THE LOWER LIP. 151 

Horizontal fissure is the result of failure on the part of the edges of 
the highest branchial arch to unite. An enormous enlargement of the 
mouth (macrostoma) is formed ; the mouth may reach from one ear to 
the other. Skin appendices in front of the auricle are sometimes seen 
in connection with this deformity (^1, Fig. 196). 

Angular fissure is sometimes observed. Fergusson records an in- 
stance in which the cleft extended from the left angle of the mouth to 
the base of the lower jaw. A case is quoted by Beeley ' in which the 
mouth was properly formed, but from beneath the left angle a cleft began 
which ran obliquely to the median line. The cleft was lined with mucous 
membrane and provided with a sphincter muscle. When the child's face 
was at rest the cleft appeared to be closed ; when it cried the cleft gaped 
widely, and led into a hollow space lined with mucous membrane which 
lay between the cheek and the cavity of the mouth. A ranula was also 
present. 

Congenital Deformities op the Lower Lip. 

Median cleft of the lower lip is of very rare occurrence, from the 
fact that this structure corresponds to the second branchial arch, and 
therefore is developed as a whole from the first. It has been observed, 
however, by Ribel. Cleft of the lower lip occurring in connection with 
deft of the inferior maxillary bone and tongue has also been observed 
(Parise). 

Congenital fistula of the lower lip occurs with comparatively 
greater frequency than the foregoing. Fritsche has collected fifteen 
instances of the anomaly. In the majority of instances it has been 
associated with hare-lip. These fistulse are lined with mucous mem- 
brane, and approach almost to the mucous membrane of the mouth, 
without, however, communicating with the latter. They may also take 
the shape of a transverse fissure, resembling a second oral orifice. Trunk- 
like enlargement of the lower lip has been observed in some cases. 

Metoplastic Operations. 

These operations are designed to correct defects in the soft parts of 
the cheeks. They are less frequently required than plastic procedures in 
other portions of the face, but are correspondingly difficult of execution 
in most instances. The skin of the neck and temporal region and of the 
forehead is employed for this purpose in complete loss of substance. The 
skin of the first- and last-named localities is that most frequently utilized : 
when taken from the neck the resulting scar may produce distortions of 
the head. Fortunately, complete loss of the cheek occurs very infre- 
quently. 

Sohimmelbusch's Operation. — After the removal of the entire cheek 
for malignant disease the defect was filled in by means of flaps taken 
from both the neck and scalp. The flap from the neck reached nearly 
to the clavicle, and when turned up into position its skin surface 
replaced the buccal mucous membrane. The flap from the scalp when 
turned downward presented its raw sui'face to that of the neck-flap, 
while its outer hairy surface replaced the beard. Cicatricial contraction 

' Handbuch der Kinderkrankheiten, vol. vi., Part II., p. 98. 



162 PLASTIC SURGERY. 

is prevented by this method, and the movements of the jaw are not 
interfered with. The pedicles are divided in four weeks.' 

In partial defects the particular procedure to be adopted will depend 
upon conditions present. Flaps with narrow pedicles are successfully 
employed on account of the rich blood-supply of the parts. In making 
these allowance must be made for possible distortions resulting from 
approaching too closely to the eyelids or lips to obtain large flaps. 

The flap employed to correct a perforation of the cheek is apt to 
undergo contraction upon its buccal surface. In extirpation of growths 
from this region, therefore, the mucous membrane should be spared, if 
possible, for the reason that it is not easily replaced. Sliding of flaps 
of mucous membrane is not very successful. 

Cicatricial lockjaw, following noma, presents one of the greatest dif- 
ficulties in metoplastic procedures. Here the cicatrix must be divided 
and the gap filled in ^vith double skin-flaps, the integumentary sur- 
faces of which present, the one upon the side toward the cavity of the 
mouth and the other externally (Gussenbauer). In this manner recon- 
traction, to a great extent, is avoided. 

Haee-lip and Oleft-palatb. 

Congenital clefts of the facial region are the result of a failure to 
coalesce of the various foetal clefts between the branchial arches in the 
cephalic extremity. The union of these arches, which should occur 
at about the ninth or tenth week of foetal life, failing or occurring in 
an incomplete manner, various deformities follow, the chief of which 
are harelip and cleft-palate. 

Hare-lip. — Hare-lip occurs very rarely in the lower lip, for the rea- 
son that the latter is formed, as a whole, from the mandibular or second 
branchial arch, which is complete from the beginning in the great major- 
ity of cases. Cases of cleft in the loirer lip are reported by Ribel, and 
Parise reports simultaneous cleft of the inferior maxilla and tongue in 
addition to cleft of the lower lip. Fistula of the lower lip is sometimes 
observed associated with hare-lip in the usual location. 

Varieties and Complications. — Hare-lip may be single, double, or com- 
plicated with cleft-palate. Almost without exception it is laterally placed 
in the line of one or the other naris. In rare instances a median cleft 
has been observed, but there are instances in which associated deform- 
ities are present, such as absence of the ethmoid, turbinated bones, nasal 
bones, vomer, and premaxillary bones. Single hare-lip occurs much 
more frequently than double (ten to one), and those upon the left side 
far outnumber those upon the right. In fact, arrest of development 
in general is said to occur upon the left side more frequently than upon 
the right. 

Degrees of Hare-lip. — Three degrees of hare-lip are distinguished. 
The first is a mere notch (Fig. 197) passing but slightly beyond the 
vermilion border; the second extends to the nasal orifice, there termi- 
nating (Fig. 198) ; the third connects the mouth and corresponding nasal 
fossa into a common opening through the medium of the cleft (Fig. 199). 
The first two are, as a rule, uncomplicated, while the third is usually 
' Verhandlungen der Berliner med. Qesellschaft, Dec. 1, 1892. 



H ABE-LIP AND CLEFT-PALATE. 



153 



associated with cleft-palate and failure of union of the intermaxillary 
bone. This stage is frequently reached in single hare-lip ; it is the rule 

Fig. 197. Fig. 198. 





Hare-lip : first degree. Hare-lip : second degree. 

in the double variety, in which case two fissures of the alveolar arches 
are also present. The fissures in double hare-lip, in exceptional in- 
stances, may not both ascend to the same level, that upon one side being 

Fig. 199. Fig. 200. 





Hare-lip: tliird degree. 



Hare-lip : complete upon one side and 
incomplete upon the other. 



Fig. 201. 



complete, while that upon the other may reach only the first or second 
degree (Fig. 200). In double hare-lip and cleft-palate the outer or 
premaxillary bone is separated from the alveolar arches. This bone 
carries the central incisor teeth ; sometimes the number of the latter is 
in excess of the normal. 

Double Hare-lip. — Double fissures, as a rule, do not pass beyond the 
cleft which separates the premaxillary bone from the alveolar arches, 
the vomer and palatine process of the superior maxillary bone joining 
upon one side. Even where this does not occur, and a double osseous 
cleft is present, but a single cleft of the 
."oft parts covering the hard palate occurs. 
The prominence of the intermaxillary 
bone is produced by its freedom from re- 
straint in double fissure, the growth of 
the vomer crowding it forward (Fig. 201). 

Various functional disturbances arise 
from the presence of hare-lip and cleft- 
palate. In cases of the former involving 
a lateral cleft to the first and second de- 
gree the cosmetic effect surpasses in im- 
portance disturbances of function, which 
are comparatively unimportant, the formation of the labial sounds being 




Prominence of the intermaxillary bone 
in double hare-lip. 



154 PLASTIC SURGERY. 

alone interfered with. In complete fissure, however, grave disturbances 
may occur. Interferences with nutrition result from inability of the 
child to suckle properly, and bronchitis and pneumonia may result from 
the inspiration of air which has not been freed from dust and other 
irritating qualities by passing over a proper surface of normal mucous 
membrane. These dangers threaten particularly during the first year 
of life. In addition to the failure to produce labial sounds incident to 
cases of simple fissure, in those complicated by palatal cleft the air passes 
to both the nasal and oral cavities, and the voice assumes a nasal cha- 
racter, which interferes greatly with the formation of intelligible speech. 

An hereditary predisposition to hare-lip has been suggested in view 
of the number of cases which have been observed to occur in the same 
family. 

Operative Treatment. — In the operative treatment of hare-lip the time 
to be selected for the operation is of considerable importance. The French 
surgeons, as a rule, insist upon early interference in all cases. While many 
considerations impel the surgeon to correct the deformity as early as possi- 
ble — notably those arising from the desire to calm the anxieties of the 
mother, as well as those referring to the dangers which threaten the child 
itself — on the other hand the condition of the child should be borne in 
mind. There are some very good reasons for counselling delay in weak and 
poorly-nourished infants, chief among which are, first, the fact that very 
young infants do not bear the loss of blood Mell at best, and, second, the 
gastro-intestinal irritation which is apt to be set up by the swallowing of 
blood will sometimes turn the scale against the child. Children, however, 
who have apparently thriven well upon the artificial feeding which is 
usually necessary may be operated upon at any time after they have 
become accustomed to the latter. Weak and ill-nourished children had 
best have the operation deferred for a few months, unless it is apparent 
from the conditions present that the malnutrition depends upon the 
deformity itself. As a rule, those with double hare-lip are deferred, 
other things being equal, until a later period than that selected for single 
hare-lip. A child of a year is none too old to bear well the operation 
for double hare-lip. Cases complicated with cleft-palate, whether single 
or double, should be operated upon not later than a year. With closure 
of the labial cleft the palatal defect during the succeeding few months 
grows narrower — an advantage which is manifest when the time comes 
for wearing a prothetie apparatus or closing the cleft-palate. 

The Ancesthetio. — The question of the administration of an anaesthetic 
is to be carefully considered. While, on the one hand, ansesthesia per- 
mits a more accurate operative procedure, on the other a greater quantity 
of blood is swallowed, and inspired as Avell. In spite of this, the general 
preference is for chloroform ansesthesia. If the operation is performed 
without an anaesthetic, the child is wrapped tightly in a small blanket and 
fastened in a high chair, the chair, child, and all being tipped back so as 
to rest in the lap of the operator, sitting behind. 

General Operative Technique. — In considering the general technique 
of the operative procedures for the cure of hare-lip the most important 
points relate to — (1) the prevention of hemorrhage ; (2) the instruments ; 
(3) the manner of making the incisions ; (4) the relief of tension ; (5) 
the sutures. 



HARE-LIP AND CLEFT-PALATE. 



155 



In former times special pressure-clamps for preventing hemorrhage 
were employed. The fingers of an assistant grasping the lip upon either 
side of the cleft serve the purpose much better, but these are somewhat 
in the way. An exceedingly useful device is to pass a loop of thread 
through the lip at a sufficient distance away from the edge of the cleft to 
be out of the way, and in a situation to control the bleeding from the 
coronary arteries (Fig. 202). This loop is given in charge of an assistant. 

Fig. 202. 




Temporary sutures controlling the coronary arteries and serving as retractors. 

It need not be tied, as this would distort the parts ; sufficient pressure 
can be made by simple traction upon it. The loop is to be removed as 
soon as the first one or two sutures are applied. 

The necessary instruments are few and simple. A straight bistoury 
with a rather thin blade serves best for the formation of the flap. The 
edges to be freshened may be denuded with scissors, or the bistoury may 
be likewise here employed. Scissors, while they may be guided a trifle 
more accurately perhaps, produce more contusion of the parts. A pair 
of mouse-toothed forceps or a firm tenaculum to steady the flap as it is 
formed will also be needed. A pair of blimt scissors, curved upon the 
flat, and a half-dozen medium-sized and slightly-curved Hagedorn needles 
will also be required. 

In making the incisions for the formation of the flap, as well as those 
for freshening the edges, the point of the knife is passed through the 
entire thickness of the lip, the edge being steadied by the forceps or 
tenaculum. The flap is to be cut after the manner described in the 
N§laton, the Mirault-Langenbeck, or the Simons method. After fash- 
ioning the flap the edge of the flap toward the median line is freshened. 
In order to ensure firm union of the sutured edges the wound-surfaces 
are made as broad as possible. It is recommended by some surgeons, in 
order to accomplish this, to split the edges of the cleft in a dii'ection 
parallel with the surface of the face, instead of or in addition to fresh- 
ening them. The split edges are then broadened, the skin-surfaces being 
brought together from the edges of the cleft to form a fold without, and 
sutured, while the mucous surfaces are brought together to form a fold 
within, and likewise inverted. This procedure occupies more time, and 
involves additional risk in young and weak infants. 

Before the sutures are applied the wound-edges must be relieved of 
tension when brought together, in order that the former may not cut 
through. For this purpose diiferent incisions are made. The most 



156 PLASTIC SURGERY. 

practicable, and the method involving the least loss of blood, consists in 
detaching with the scissors the lip from the gum, the scissors being made 
to follow the bone closely, and the tip of the left index-finger held in 
such a manner as to act as a guide, at the same time serving to lift the 
structures of the lip away from the upper jaw in an upward and outward 
direction. The scissors should be directed toward the superior maxilla 
throughout this entire dissection, and not toward the cheek, in order to 
avoid the vessels. The incisions are made on both sides, and the super- 
ficial bleeding arrested by pressure. The frsenum of the upper lip is 
completely separated. These relaxation incisions heal readily. Their 
effects are at once manifest when the edges of the cleft are brought to- 
gether. By their employment cheek-compressors, which fret and worry 
the child, can be dispensed with. 

The first suture, in whatever operation chosen, should be applied in 
such a manner as to serve to arrest the hemorrhage, thus dispensing with 
the fingers of an assistant or the loop of thread employed for this purpose. 
For the rest, alternating deep or tension and superficial or coaptation 
sutures are to be applied. In addition, particular attention is to be paid 
to the accurate adjustment of the edges at the vermilion border. 

Either silk thread or silkworm gut is to be employed. Catgut is not 
to be relied upon for this purpose. If the tension has not been entirely 
relieved, the button variety may be used for the deep sutures. The 
superficial approximation is best accomplished by the simple interrupted 
suture. In tying the knots of the sutures care should be taken that these 
do not rest upon the line of union, in which situation they may produce 
sloughs or otherwise interfere with rapid healing. Hare-lip pins and 
the figure-of-8 sutures are no longer employed. 

Methods of Operation in Single Hare-lip. — Ndaton's Operation. — 
Fissures of the first and second degree are corrected as follows : The 
point of a straight bistoury is entered about 8 mm. above the angle and 
passed through the entire thickness of the lip. It is then carried in a 
direction parallel to the edges of the cleft and at a sufficient distance from 
the latter, downward toward, but not quite to, the vermilion border. 
This is separated on the opposite side. A A-shaped incision is thus 
formed (Fig. 203). By passing a tenaculum through the apex of the 

Fig. 203. Fig. 204. 





Naatou's operation : the incision. NSlaton's operation : the sutures. 

cleft and drawing down upon the loosened flap, the legs of the A are 
inverted and a rhomboid space is formed (Fig. 204), which is closed by 
suturing edge to edge. The amount of projection in a downward direc- 
tion at the vermilion border is to be graduated according to the require- 



HABE-LIP AND CLEFT-PALATE. 



157 



ments of the case. It should be borne in mind that unless an over- 
correction of the deformity is made the subsequent contraction of the 
vertically-placed scar will result in an unsightly notch. 

Hagedorn's Operation. — A curved incision (Figs. 205, 206) made by 
transfixion with a sharp-pointed straight bistoury is made to follow the 



Fig. 205. 



Fig. 206. 





Hagedorn's hare-lip operation. 



vermilion border of the lateral side of the cleft, and another incision, 
shown at 4-3-2, is made on the median margin. The incisions (5-1-4) 
are made obliquely across the border, and two shorter incisions at 2, also 
including the border, complete the removal of the whole of the margin 
from 5 to 2. The points on either side of the fissure marked by corre- 
sponding figures are brought together. 

Dieffenbaoh's Operation. — In cases of the third degree this last- 
named method is not applicable. Here concave freshening of the edges, 
after Dieffenbach's or some one of the procedures designed to lengthen 
the edges of the flap, is indicated. Simple concave freshening has 
now been very generally abandoned in favor of the more rational 
methods which involve comparatively slight or no loss of tissue. 

Malgaigne's Operation. — Among the favorite procedures of the pres- 
ent day is that devised by Malgaigne. The incision is begun at the 
upper limit of the cleft, and is carried downward toward the free border 
of the lip, but not through the latter. A similar flap is made upon the 
other side (Fig. 207). Two small flaps, which are adherent to the lip by 



Fig. 207. 



Fig. 208. 




B B 
Malgaigne's operation : the incision. 




Malgaigne's operation ; the sutures in posi- 
tion ; the lower sutures tied. 



a pedicle, result. These are turned downward (Fig. 208) as in N^laton's 
operation, and the resulting space closed by suturing. 



158 



PLASTIC SURGERY. 



Fig. 209. 



The Mirault-Langenhech-Dix Operation. — Where the two edges of 
the flap are not nearly parallel, as sometimes happens, the outer edge 

having an inclination outward and down- 
ward, Malgaigne's operation is inferior 
to that devised by Mirault and modified 
by Langenbeck. In Mirault's opera- 
tion but a single flap is employed. This 
is taken from above downward, but left 
attached at the prolabium (Fig. 209). 
On the other or median side the cleft 
margin is removed completely. Lan- 
genbeck modified this portion of the 
operation by freshening at an obtuse 
angle the margin corresponding to the 
median edge of the cleft. Dix further modified this by sloping the 
freshened edge so as to remove more of the mucous membrane than of 
the skin, and treating the flap in a converse manner — i. e. by removing 
more of the skin than of the mucous membrane (Fig. 210). A more 




Mirault-Langenbeck operation. 



Fig. 210. 



Fig. 211. 




Dix's modlflcation of the Miranlt-Langenbeck 
operation : the bevel-shaped flap. 




<Si^ 



The Mirault-Langenbeok operation: the 
sutures. 



accurate adjustment of the edges is possible by this modification. Fig. 
211 shows the method of suturing. 

G. Simon's Quadrangular-flap Operation. — The method by quad- 
rangular flap by G. Simon is sometimes employed. In place of the 



Fig. 212. 



Fig. 213. 





G. Simon's quadrangular-flap operation. 



G. Simon's quadrangular-flap operation, 
showing the adjustment of the parts. 



tongue-like flap of Mirault a quadrangular flap, 3 or 4 mm. broad, is 
made (Fig. 212), and a corresponding freshening of the opposite edge of 



HARE-LIP AND CLEFT-PALATE. 



159 



the cleft. The Li -shaped line, when the flap and freshened edges are 
brought together and sutured, forms a very complete correction to the 
deformity (Fig. 213). The upper portion of the cleft where it passes 
into the nostril is ireshened and sutured independently. One advan- 
tage which this operation possesses is that the cicatricial contraction is 
distributed over three separate lines, the minimum amount of shrinkage 
at the vermilion border occurs, and a lip much more sightly in every 
way is thus formed. 

Girald^' Operation. — Giraldfes' procedure is what is known as the 
" mortise operation." It is described as follows : First, an outer flap (i?) 
is formed, attached below, as in Mirault's operation (Fig. 214). Second, 
an inner flap is formed (JD) by cutting from below upward ; this flap 
is left attached near the upper limit of the cleft, near the nostril. 



Fig. 214. 



Fig. 21.5. 




B A 

The incision in Girald^s' operation. 




GiraldSs' operation ; the sutures in position. 



Fig. 216. 



Third, a horizontal incision is made (Par6 ; Guillemeau ; Van Home) 
to increase the flap, at C. The flap A is now brought down, the flap B 
is carried up so as to form the edge of the nostril, and the freshened 
edges thus brought into apposition are sutured (Fig. 215). 

Golding-Bird's Operation. — This is known as " the rectangular 
operation." After freely loosening the parts from the bone the upper 
angle at one side is transfixed, and the 
cut carried downward till the lower 
angle is reached [A, B, Fig. 216) ; the 
knife is now turned and carried horizon- 
tally {B, C) for a short distance. At 
the middle of this horizontal line a ver- 
tical cut extends through the vermilion 
border. A similar incision is made upon 
the opposite side (A, F, G), omitting the 
horizontal cut. Both skin and mucous- 
membrane sutures are employed. The 
resulting scar resembles somewhat that following Mirault's or GiraldSs' 
operation. 

In the selection of an operation the following should be borne in 
mind : In new-born children and during infancy and early childhood 
the operation chosen should be the simplest that can be adapted to the 
exigencies of the case, the object being to avoid as far as possible large 
losses of blood. Later in life, if the surgeon desires or the vanity of 
the patient prompts, more complicated procedures may be employed. 

It becomes necessary occasionally to equalize the openings in the 




Golding-Bird's operation. 



160 PLASTIC SURGERY. 

nostrils, for the reason that, following the most perfectly devised opera- 
tion, one naris will be found to be much larger than the other. This 
is best accomplished by detaching the cartilaginous septum from the 
floor of the nasal cavity and carrying it toward the wider nostril, having 
previously freshened a surface at this point for its reception. It is here 
sutured, and the side from which it was displaced kept plugged with 
antiseptic gauze for a few days. Operations of this character are best 
performed after the lapse of several years following the original pro- 
cedure. 

Operations fob Double Haee-lip. 

Time f<yr Operation. — While single hare-lip may be operated upon 
comparatively early in life, in double hare-lip it is better to delay the 
operation until the second year of life if the nutrition of the child can 
be maintained in spite of the deformity. As before stated, failure in 
this respect may necessitate an earlier operation. 

Disposition of the Intermaxillary Bone. — In operations for double 
hare-lip an important question for discussion relates to the disposition 
to be made of the intermaxillary bone. In cases of but slight elevation 
or of entire absence of the projection the labial clefts may be closed at 
once. Usually, however, the intermaxillary bone will be found to be a 
serious obstacle in the way of a restitution of the parts. If the case is 
sufficiently favorable to permit of closure of the labial cleft at once, this 
exercises a favorable influence over both the cleft and the prominent 
bone. The latter gradually recedes to its normal position and unites 
with the alveolar processes. In a very marked prominence, however, 
this should not be attempted, for the reason that the displaced bone will 
exercise such an amount of pressure as to prevent union of the soft 
parts. Under these circumstances the prominence of the intermaxillary 
bone must be reduced. 

The removal of the intermaxillary bone at the present day must be 
considered as but little short of an unjustifiable mutilation. Its func- 
tional and cosmetic uses are such as to demand its retention. In order 
to efifect its reduction different methods have been devised, such as — (1 
forcible fracture and crowding backward of the vomer (Gensoul) ; (2* 
excision of a triangular portion of the vomer close behind the inter- 
maxillary bone (Blandin) ; (3) simple vertical section of the vomer and 
overlapping of the two sides (Rose) ; and (4) the method of uniting long 
flaps of both lips and cheek with the central portion, without regard to 
the cosmetic effect, and trusting to the pressure of the thus restored 
margin to reduce the projection. A plastic operation is resorted to 
afterward in order to improve the shape of the mouth (G. Simon). The 
method of Gensoul is applicable only after ossification of the vomer 
has taken place ; it will be found impossible to fracture the vomer while 
in its cartilaginous condition. Simon's method is objectionable because 
of the length of time occupied and the very unsatisfactory condition of 
the parts in the interval. Blandin's procedure, or some one of its mod- 
ifications, is greatly to be preferred. 

Blandin's Method of Reducing the Intermaxillary Bone. — Blandin's 
original procedure, which consisted of the removal of a triangular-shaped 



OPERATIONS FOB DOUBLE HABE-LIP. 



161 



piece of the vomer, together with its covering (Fig. 217), is open to the 
objection that hemorrhage difficult to control frequently attends its 
employment. In addition, failure of union between the posterior border 
of the intermaxillary bone and the vomer occurs. The first disad- 



FiG. 217. 




Antero-posterior section through intermaxiUary bone, vomer, etc. : F. Blandin's operation for the 
removal of a triangular-shaped portion of the vomer. The dotted line marks the site of 
the division of the vomer in Rose's operation. 

vantage could be overcome by the thermo-cautery, or Bruns' temporary 
compression loop passed through the vomer behind the point of pro- 
posed excision. Failure of union, however, would still constitute a 
serious objection. 

Modifications of Blandin's Procedure. — Almost simultaneously, in 
1868, four surgeons, Bardeleben, Guerin, Delorme, and Mirault, suggested 
essentially the same modification of Blandin's procedure. This consists 
in making a subperiosteal resection of the vomer. This is done through 
an incision along the edge of the vomer, lifting the muco-periosteal 
covering of the bone from the latter by means of a slender elevator, and, 
holding these out of the way by means of retractors, the triangular por- 
tion of the bone is removed by means of a pair of stout scissors. The 
remainder of the vomer is now forced back to its normal position from 
in front. 

Rose's Procedure. — Rose, in modifying Blandin's operation, after sep- 
arating the muco-periosteal coverings, as in the last-named procedure, 
made a simple vertical cut through the entire thickness of the vomer 
(Fig. 216), and then forced the anterior portion of the bone backward, 
causing the two portions to overlap each other, the lateral surfaces be- 
coming united. 

Either of these modifications will give a very satisfactory result. If 
care is taken to keep the elevator close to the bone while lifting up the 
covering of the latter, no vessels of importance are injured and the 
operation is almost a bloodless one. 

Steps of the Operation for Double Hare-lip. — The steps of the opera- 

VOL. II.— 11 



162 



PLASTIC SVRQEBY. 



Fig. 218. 




Fig. 219. 



tion for double hare-lip are as follows : (1) The skin overlying the central- 
portion or the intermaxillary bone is pared at its margins so as to leave 
a quadrangular space with thin wound-surfaces (Fig. 218, A, A, A). On 

no account should the strip of skin upon 
the intermaxillary bone be removed or dis- 
placed upward to lengthen the nasal septum, 
as was formerly taught. (2) From the outer 
edge of each cleft is formed a flap similar 
to that formed in Malgaigne's operation for 
simple hare-lip, these flaps remaining at- 
tached each by a pedicle to its correspond- 
ing portion of the lip (Fig. 216, D, D). 
The operation for double hare-lip. (3) The remainder of the outer edge of each 

cleft is freshened by removing the margins 
above the point from which the flaps were talven in an upward direction 
to the alas of the nose (Fig. 216, C, C). (4) The flaps taken from the 
outer edges of the clefts are now approximated to the horizontal surface 
of the tip of the central portion, the thin extremity of each flap being 
trimmed with the scissors so as to meet in the middle line, where both of 
the clefts ai-e closed. The tension must be relieved by loosening the lip 

and cheek from the superior maxillary bone 
with scissors, as heretofore described. The 
parts when ready for suturing should appear 
as in Fig. 219. 

After-treatment. — Dressings. — Ordi- 
nary dressings should not be applied after 
the operation of hare-lip. The restlessness 
and irritability which they produce more 
than outweighs the benefit derived. Thor- 
ough drying of the edges of the wound and 
pencilling with collodion mixed with iodide 
of bismuth constitutes the best dressing. 
Even this is sometimes omitted with advan- 
tage, occasional cleansing being substituted. 
Every effort should be made to prevent the child from crying. Feed- 
ing should be carried on with a small spoon. The entire attention of 
the nurse or mother should be directed to this end. The oral cavity 
should be cleansed by means of bits of absorbent cotton grasped in a for- 
ceps or tied upon a stick, and dipped in a solution of boric acid of about 
the strength of a drachm to the pint. If the bowels do not move within 
the first twenty-four hours, a suitable purge should be given. One or 
more dark-colored alvine dejections will usually occur as a result of the 
blood which has been swallowed. 

Removal of the Sutures. — The sutures should be removed on or about 
the sixth day. The union may be complete or partial. If only the 
vermilion border has united, the gap left by failure of union of the 
remainder of the cleft will close by granulation. This may be assisted 
by approximating the granulating edges with adhesive plaster. Should 
complete failure of union occur, an attempt may be made to bring the 
edges together by secondary sutures. Usually, however, the tissues will 
not bear the strain of these in their softened and inflamed condition ; a 




Operation for double hare-lip 
sutures in position. 



the 



CLEFT-PALATE. 163 

second operation after from four to six weeks, following the first opera- 
tion, should be done by preference. 

In cases in which a fatal result follows the operation, death takes 
place either from hemorrhage, or from broncho-pneumonia. 

Cleft-palate. 

Palatal defects or fissures are either congenital or acquired. In the 
former the cleft may only involve the soft parts, or both hard and soft 
palate may be the site of the defect, in which case hare-lip is usually 
associated. While fissure of the soft palate may occur without that of 
the hard palate, defect of the latter is always associated with a split of 
the velum. 

In some cases of cleft-palate neither of the palatine processes reach to 
the vomer ; in others one palatine process passes to the vomer, while 
that of the other side does not. Finally, one palatine process may be 
partly attached — i. e. anteriorly and posteriorly, with a cleft between. 
When neither palatine process reaches the voiner, the intermaxillary 
bone is carried forward by the projecting lower edge of the vomer : this 
condition is usually associated with double hare-lip. When either of the 
palatine processes is attached to the vomer, the latter is simply deflected 
toward the fissured side ; here single hare-lip is generally present. 

Fissures of the Soft Palate. — Fissures of the soft palate are, almost 
without exception, placed exactly in the median line. Even the uvula 
is split exactly in the middle, one half of it and the velum hanging upon 
either side. The muscular apparatus is normally developed. When the 
soft palate alone is aifected the fissure terminates in an acute angle at the 
posterior edge of the hard palate, or even invades this for a short dis- 
tance. There may be all degrees of fissure, from the above to a slight 
split of the uvula alone (bifid uvula). Defects of the hard palate, on 
the other hand, are almost necessarily asymmetrically placed. 

Acquired Cleft-palate. — The causes of acquired cleft-palate include 
perforating wounds and constitutional syphilis. Those due to trau- 
matism may vary in form and extent ; those due to syphilis, however, 
present a rather constant and characteristic form. The fissure is of an 
oval or oblong shape. The syphilitic lesions are mainly confined to the 
velum pendulum palati, and various degrees of destruction of this 
structure may be present. The gummatous infiltration is usually at 
first in the median line, and one or more perforations of the velum may 
arise. Fusion of several of these may lead to the oval opening above 
alluded to. Much more frequently, however, the ulceration extends 
from the posterior surface of the velum to the lateral pharyngeal wall, 
and subsequent cicatricial contraction drags the margins of the remains 
of the soft palate to either side, and the site of the former velum is 
occupied by a triangular-shaped defect, the cicatricial edges of which 
seem welded to the lateral pharyngeal wall, and enclose a large opening 
which leads in an upward direction to the nasal fossa, and downward to 
the rima glottidis. 

Functional Disturbances. — Deglutition. — The functions of degluti- 
tion and speech are essentially interfered with in cleft-palate. In the 
first named the food is crowded into the nasal fossa by the action of the 



164 



PLASTIC SURGERY. 



Fig. 220. 



tongue in attempting to force it into the pharynx. The latter organ 
becomes in some instances unduly developed in the constant attempts to 
perform this portion of the process of deglutition properly. The mus- 
cular structures of the palatine region in fissures of the velum are also 
developed beyond the normal. This is particularly true of the muscular 
fibres upon the posterior pharyngeal wall, which by their action seem to 
resist the tendency of the food to pass upward to the nasal cavity upon 
contraction of the lower pharyngeal constrictors. In 
spite of this, however, small particles of food pass into 
the nasal cavity in children, and produce not only 
considerable inconvenience, but some dangers from 
decomposition and consequent inflammatory condi- 
tions. This is particularly true of curdled milk, 
which in infants still upon the bottle may pass into 
the recesses of the turbinated bones and give rise to 
aphthous patches here. A nipple with a shield- 
shaped device may be advantageously employed to 
prevent this (Fig. 220). 

Interference with Speech. — The principal intei'fe- 
rence with the function of speech relates to the enun- 
ciation of vowel sounds. This arises from the 
failure to properly shut off the nasal cavity from 
that of the mouth. The extent of this interference 
with speech will depend (1) upon the size of the 
cleft, and (2) upon the greater or less ability on the 
part of the patient to shorten this by muscular effort. 
The interference with speech may thus reach all 
grades, from a slight nasal intonation to an absolute 
unintelligibility. Acquired cleft is not so apt to give 
rise to the extreme degrees of interference. This is 
particularly true of syphilitic destruction of the soft palate, the cicatri- 
cial contraction so narrowing the naso-pharyngeal communication that 
but slight effort is required on the part of the surrounding muscular 
structures to complete the closure. 

In cases in which large palate defects exist, the formation of such 
sounds as depend upon the approximation of the tongue to the roof of the 
mouth is interfered with. In fact, between imperfect formation of the 
last named, as well as such explosive sounds as b and p, which require 
a preliminary filling of the oral cavity with air, and inability to pro- 
nounce the vowels and many of the consonants, attempts at vocalization 
are sometimes absolutely futile, as well as exceedingly painful to witness. 
Treatment by Obturators, etc. — Patients will sometimes instinct- 
ively attempt to fill the defect with foreign bodies, portions of food, etc. 
Obturators of various kinds have been devised by the dentists. These 
are fastened to the teeth, and for this reason their employment must 
necessarily be postponed until the teeth have appeared. By this time a 
habit of speech will have been formed which only careful and painstak- 
ing training can overcome. Kingsley of New York has introduced to the 
profession an artificial palate and velum, the aim of which is to replace, 
as far as possible, the natural form of the defective parts with such mate- 
rial as shall restore, to some extent, their function. For this purpose 




Nipple and shield 
(Mason). 



CLEFT-PALATE. 165 

the velum portion of the obturator is made of soft vulcanized rubber, 
and this soft elastic substance, filling the gap in the soft palate with a 
flap behind as well as in front, enables it to follow the movements of the 
muscular apparatus upon either side with which it comes in intimate 
contact. 

Siierson's method of correcting the deformity by apparatus is as fol- 
lows : A horizontal plate is placed in the pharyngeal cavity, separating 
the upper portion of the latter, or naso-pharyngeal space, from the lower. 
A bridge connects this with the portion of the apparatus which covers 
in the defect of the hard palate, which portion is attached to two of the 
teeth. This bridge is received into the fissure of the soft palate. In 
order to provide for nasal respiration, and at the same time permit of 
such sounds as require vibration of the air contained in the nasal cavity, 
the plate for the pharyngeal portion of the apparatus is made after a 
wax model, which in its turn is moulded into shape in the patient's 
pharynx and while he is enunciating the sounds above alluded to. The 
contracting muscular structures produce certain impressions in the wax, 
and with this as a model these are reproduced in the gutta-percha 
pharyngeal plate. While the parts arq at rest a space is left for nasal 
breathing, but when the muscles are brought into play for the production 
of sounds the nasal cavity is closed and the nasal sound of the vowels 
prevented. The same principle may be applied in the correction of 
acquired cleft-palate. 

Operative Treatment of Cleft-palate. — The operative procedures 
instituted for the cure of cleft-palate are called, in the case of the soft 
palate, staphylorrhaphy, and in the case of the hard palate, uranoplasty. In 
1816, Roux and Grafe almost simultaneously attempted the operation of 
staphylorrhaphy, and DiefFenbach later introduced the lateral incisions 
through the velum for the purpose of relieving the tension. Division 
of the levator palati muscles for the latter purpose, suggested by Fer- 
gusson, was found to be still more effective. 

Time for Operation in Cleft-palate. — The mortality from cleft-palate 
operations in early infancy, say before the fourth month, amounts to 
almost 50 per cent. (Ehrmann). The most favorable time for operation 
is at the fifth year (Schede), although Ehrmann concludes, upon the 
basis of an experience in fifty cases, that uranoplasty usually interferes 
with the development of the skeleton of the arch, and for this reason he 
believes that operations should be postponed to the period of the second 
dentition (the tenth or twelfth year). 

The frequent failure to procure a good functional result when ope- 
rations were done after the child commenced to talk was attributed to the 
late operation and the necessity for extensive myotomy and its conse- 
quent crippling effect (Wolff). No better functional results, however, 
follow early operations. Sloughing of the muco-periosteal flaps in very 
young infants also constitutes a risk to which particular attention has 
not hitherto been drawn. 

The Employment ofAncesthetics in Staphylorrhaphy and Uranoplasty. — 
Rose's dependent head position is to be employed in cleft-palate ope- 
rations. The patient's head is placed at the edge of the table, and a hard 
roller or cushion placed beneath the neck in such a manner as to elevate 
the chin and depress the occiput, the head hanging over the edge of the 



166 



PLASTIC SURGERY. 



cushion. The larynx is above the level of the oral and the nasal cav- 
ities, and the blood cannot pass into the air-passages, but flows out of the 
nose and mouth (Fig. 221). Prior to its introduction it was deemed an 



Fig. 221. 




Kose's dependent head position : A, level of glottis opening ; B, level of nasal opening— to show 
escape of blood from nose during operation. 

exceedingly dangerous procedure to undertake the operation under an 
ansesthetic, on account of the amount of blood which would almost in- 
evitably find its way into the air-passages. Since the introduction of 
cocaine ansesthesia this agent is employed in a solution of from 10 to 20 
per cent. Although this will assist 

materially in lessening the pain, the Fig. 223. 

deeper parts will remain sensitive in 
spite of its use. It should be very 
sparingly employed in young chil- 
dren. 

Mouth-gags for Operaiions upon 
Cleft-palate. — The employment of 
suitable mouth specula or gags for 





Fig. 222 




/ 




-^^ 






^fe^ 



Gower's gag. 




O'Dwyer's gag. 



facilitating access to and manipulation within the oral cavity is of the 
greatest importance. Of these there are emploved Gower's (Fig. 222), 
O'Dwyer's (Fig. 223), French's (Fig. 224), and "Whitehead's (Fig. 225), 



OPERATION OF STAPHYLORRHAPHY. 



167 



The last-named has a tongue-depressor attachment. When the others 
are used it will be necessary to pass a thread through the tongue in order 
to hold this organ out of the way. The first-named affords the largest 
working space, which may be very materially increased by the cheek- 
retractor (Fig. 226). 

Fig. 224. 




French's gag. 
Fig. 225. 




Whitehead's gag. 

Fig. 226. 
edgewise view ' 




Cheek-retraetor. 

Operation of Staphylorrhaphy. 

Paring the Edges. — The paring of the edges of the fissure is best 
accomplished by grasping the latter at or near the angle of junction with 
the hard palate by means of a tenaculum or mouse-toothed forceps, pass- 



168 PLASTIC SUROEBY. 

ing a narrow and thin-bladed bistoury through one edge just in front of 
the angle, and by gentle to-and-fro movements cutting directly backward 
until the termination of the cleft is reached at the tip of the split uvula 
(Fig. 227). The same manoeuvre is repeated upon the other side. By 




The operation of staphylorrhaphy ; paring the edges. 

a sweeping movement a curved cut unites these together at the bottom 
of the angle, and the paring is removed in one piece, which is absolutely 
essential in order to be certain that the entire surface of both edges is 
denuded. 

Division of the Muscles. — This may be done either before or after 
the introduction of the sutures. If before, Langenbeck's sickle-shaped 
knife or Fergusson's myotomy knife may be employed. This is passed 
through the cleft, and its point introduced over the hamular process of 
the internal pterygoid plate of the sphenoid bone, which can be easily 
felt by the iinger pressed upon the soft palate in close relation to the last 
upper molar. The corresponding portion of the velum is made tense 
while the section is made. If done after the suturing, a narrow-bladed 
knife is introduced through the soft parts halfway between the hamular 
process and the Eustachian tube, and an oblique incision made out- 
wardly. The levatores palati are thus divided. The tensores palati are 
not believed to greatly influence the edges. If deemed necessary, they 
may be divided by introducing a narrow knife, with the edge upward, 
just along the inner side of each hamular process, and cutting upward a 
few lines. If the tension is not completely relieved by the division of 
the above, the palato-pharyngei should be divided by simply cutting 
across the posterior pillars, just below the tonsils, Mdth blunt-pointed 
scissors (Fergusson). 

Introduction of the Sutures. — An ordinary half-circle Hagedorn needle 



OPERATION OF STAPHYLORRHAPHY. 



169 



grasped by a needle-holder, when it can be employed, serves best for the 
introduction of the sutures. When but a narrow working space is avail- 
able, the Eeverdin needle (Fig. 228) answers better. This is passed from 



Fig. 228. 




Eeverdin's needle. 



Fig. 229. 



^ 


^^^^ 



Passing the sutures. 



one side armed, and the free end of the thread, passed through only one 

side, left loose and the needle withdrawn. The needle is now introduced 

unarmed from the other side, and the eye of the needle being opened by 

withdrawing the slide, the loose end of the 

thread is placed therein, the eye closed, and 

the needle withdrawn along with the thread, 

thus completing the suture. Or a needle with 

the eye at the point and set in a handle may 

be used in the same manner, a double thread 

forming a loop being introduced at the second 

stage, and this employed to withdraw the thus 

completed suture (Fig. 229). A good quality 

of Chinese twist is the best suture material. 

Ueanoplasty. — Special difficulties, in addi- 
tion to those met with in staphylorraphy, pre- 
sent themselves in closing clefts of the hard 
palate. Many failures followed these attempts 
until Langenbeck in 1860 developed the method known as the lateral 
muco-periosteal flap. 

Langenbeek's Operation. — This operation consists essentially in 
loosening the muco-periosteal covering of the palatal processes of the 
superior maxillary bone in the shape of lateral flaps, which are united in 
the median line to cover the defect. The advantages claimed for this pro- 
cedure are — (1) the mucous membrane and periosteum are much more 
easily detached together than the former separately ; (2) the trunk as well 
as the branches of the palatine artery are protected from injury because 
of their location between the periosteum and mucous membrane, thus 
vitality to the flap is ensured ; (3) the material employed for the correction 
of the defect is much more effective and stable than simple mucous 
membrane, even if new bone does not develop from the periosteum, as 
has been claimed. 

Inasmuch as staphylorrhaphy and uranoplasty are usually combined 
in cases of cleft of both the hard and soft palate, the paring of the edges 
described in connection with staphylorrhaphy is to be extended to 
include that of the hard palate as well. Two lateral incisions (Fig. 230), 
extending down to the bone, are now made, one at the margin of each 
alveolar border, by means of a blade shaped like a gum-lance. It is 
important that these incisions do not approach the median any nearer 
than absolutely necessary, particularly at the posterior part, for the 
reason that at this point the palatine artery passes through the palatine 
foramen to the mucous membrane, and cannot easily contract within its 



170 



PLASTIC SURGERY. 



bony channel if injured. The chisel-shaped curved elevator is now 
introduced to the bottom of the lateral incisions, and the periosteum and 
mucous membrane lifted together from the bone beneath. When this is 

Fig. 230. 




Detaching the muco-periosteal flap. 
Fig. 231. 




Line of approximation after staphylorrhaphy and uranoplasty 



completed the edge of the elevator will appear in the cleft (Fig. 231). 
Careful separation of the flap in all directions is thus secured. 

In syphilitic cases some difficulty may be experienced in separating 



OPERATION OF STAPHYLORRHAPHY. 171 

the coverings from the bone. The knife may be here applied. In con- 
genital cases, however, these lift away readily. 

The hemorrhage is usually arrested promptly by means of pressure ; 
the use of tampons soaked in ice-water is sometimes useful. If very 
persistent, tampons may be packed behind the palate, after suturing, with 
threads for withdrawal, as in plugging the posterior nares in epistaxis. 

The sutures are applied as in staphylorrhaphy. Care should be taken 
that the knots, when the threads are tied, lie to one or the other side of 
the line of union. 

Ueano-staphyloeehaphy withotjt Division of the Muscles. — 
Here the tension incisions are dispensed with. The medial plate of the 
pterygoid process is separated submucously, on a level with the base of 
the hamular process, so that by a dislocation at the point of insertion the 
palatine tension is temporarily relaxed (Billroth). Or incisions may be 
made in the usual manner in the hard palate, and the muco-periosteal 
structures, as in the latter, carefully loosened in all directions, and the 
edges of the cleft approximated and sutured. Section of the muscles 
being entirely omitted, there is less risk of interference with speech from 
this cause (Julius Wolff). 

Urano-staphylorrhaphy in Two Sittings. — It has been deemed an 
advantage, under some circumstances, to perform this operation in two 
sittings. An interval of from tAventy-four to forty-eight hours is allowed 
to elapse between the two stages. At the first sitting the usual lateral 
incisions are made on botli sides, and the muco-periosteal ilaps loosened 
from the bone ; the hemorrhage is arrested by forcipressure and subse- 
quent compression. At the second sitting the edges are pared and the 
sutures introduced. Two objects are to be gained by this procedure : (1) 
the first stage, in which considerable blood is necessarily lost, is not 
prolonged to the extent of producing an undue amount of shock, and 
the bleediag from the posterior palatine arteries is most readily arrested 
by the pressure of the overlying although loosened flaps (Polaillon) ; (2) 
the nutrition of the flaps is more certainly secured in this method of 
operating (Julius Wolff). 

Modifications. — In partial fissure — i. e. where but one nasal cavity is 
opened, the defect being confined to but one palatal process — a muco- 
periosteal flap is taken from the nasal portion looking toward the fissure, 
turned down, and sutured to the freshened edge of tlie fissure (Lanne- 
longue). In traumatic or syphilitic defects a flap from the entire thick- 
ness of the cheek may be carried in at the site of an extracted upper 
molar (Thiersch). Suturing both halves of the velum to the posterior 
pharyngeal wall (Passavant), and filling the triangular-shaped gap in 
the soft palate by a properly-shaped flap taken from the posterior wall 
of the pharynx (Trendelenburg-Schoenborn), the so-called staphyloplastic 
procedures, viewed from the standpoint of functional perfection of result, 
are worthy of further study, particularly where cicatricial contraction 
(syphilitic) exists. 

Davies-Colley Operation. — A method of closing the cleft in cases in 
which the soft parts have sloughed from previous attempts, and there 
exists too little tissue to close the palate in the ordinary way, consists of 
dissecting a triangular-shaped flap, with its base directed posteriorly, 
from one side of the cleft. A half-elliptieal-shaped flap is dissected 



172 PLASTIC SURGERY. 

from the opposite side ; this is left attached to the margin of the cleft. 
This second flap is now turned inward upon the hinge by means of 
which it remains attached to the bony edge of the cleft, its oral surface 
being directed toward the nasal cavity, M'hile its raw surface presents 
toward the cavity of the mouth. The triangular-shaped or first flap is 
now displaced, so that its raw surface approximates the raw surface of 
the second flap, and thus completes the closure of the defect. The flaps 
are secured to each other by silver-wire sutures, which are allowed to 
remain in position for from five to six weeks. In very young children 
the soft palate is closed at a second operation ; in those over twelve the 
whole gap may be closed in one sitting.^ 

After-treatment. — Frequent rinsing of the mouth with a solution 
of boric acid, potassium permanganate, or weak carbolic solution is indi- 
cated. The patient must be prevented, as far as possible, from attempt- 
ing to cough or expectorate. Nothing but liquid food is to be taken, 
and the act of swallowing performed carefully. The lateral incisions 
soon fill up by granulation, and the flaps reattach themselves to the 
bone. The sutures are removed on or about the seventh day. In cases 
of failure of union several months must elapse before the operation can 
be repeated. 

Frequent failure to realize the anticipated improvement in the voice 
follows the operation. It should be borne in mind that a congenital 
cleft in the palate is not merely a slit in the parts, but an actual defi- 
ciency of tissue exists. Hence, even after a most skilfully-performed 
operation for closure of the cleft, the velum still remains as a tight 
curtain stretched across between the oral and pharyngeal cavities and 
the posterior nares, which is too short to reach the posterior pharyngeal 
wall, and past which the air rushes from the pharynx through the pos- 
terior nares, and the peculiar nasal twang is still present. In order to 
obviate this, certain vocal exercises are not without value, but a perfect 
production of normal voice and speech by uranoplasty and staphylor- 
rhaphy has probably never been secured. It sometimes occurs that a 
hypertrophy of certain of the bundles of fibres of the pharyngeal con- 
strictors takes place, and these aid, although but ineiSciently, in seclud- 
ing the nasal cavity. 

In order to improve the voice several suggestions have been made, 
both as to prothetis and operation. In 1879, Julius Wolff directed the 
after-treatment of a case of operated cleft-palate, the dentist Schitzky 
performing the mechanical portion. A palatal plate of hard rubber is 
adjusted, and to this is attached, by a thin pedicle, a small vulcanized- 
rubber balloon which is loosely inflated with air. The latter is placed 
in such a position that the strong movement of the velum, as it is 
drawn upAvard by the levators, presses against the balloon and forces 
the contained air backward and laterally, so as to inflate the correspond- 
ing portions thereof, completely shutting off the naso-pharyngeal space. 
This device gives an almost perfectly functional result. 

Francis Mason in 1869, in order to improve the voice-sounds fol- 
lowing urano-staphylorrhaphy, made two long incisions, extending from 

' Mr. Davies-CoUey has recently described a modification and extension of this ope- 
ration. The operation has not been simplified nor made more efficient (British Medical 
Journal, April 28, 1894). 



OPERATION OF STAPHYLORRHAPHY. 173 

the site of each hamular process directly downward and backward, and 
thus released the velum laterally and converted it into a huge uvula. 
The operation is to be performed about a month after the closure of the 
cleft. This procedure enables the palate to be drawn upward and back- 
ward, partial closure, at least, of the post-nasal region and improvement 
of speech following. The patient should be encouraged to use the voice 
as much as possible after the operation. 

Passavant's procedure, and also that known as the Trendelenburg- 
Schoenborn operation, as before stated, are worthy of further trial in 
syphilitic cases, but in congenital cleft-palate, although based on correct 
physiologic principles, they are difficult of execution and unreliable as to 
their immediate results. 

While it cannot be denied that the employment of the apparatus of 
Kingsley, Siiersen, and others gives the best functional results as com- 
pared with those following the most successful operations, it is still true 
that certain cleft-palate cases should be operated upon. This is based 
upon the discomforts and inconveniences incident to the passage of food 
into the nasal cavity in some cases, and the ulcerative conditions which 
are more or less a marked feature of attempts to constantly wear an 
obturator. Closure of the palatine fissure, and the subsequent perform- 
ance of Mason's operation or the use of the Wolif-Schitsky obturator, 
gives the best results attainable by operative means in the present state 
of our knowledge. 

Acquired Palatal, Apertures. — Aside from the comparatively 
rare cases in which openings in the palate result from accidental or self- 
inflicted gunshot wounds of the roof of the mouth, these are, as a rule, 
attributed to the action of the syphilitic virus. While it is unquestion- 
ably true that syphilis may, and frequently does, produce necrosis in this 
region, and consequent loss of substance, yet cases come under the obser- 
vation of the surgeon very frequently in which no history of the primary 
lesion can be obtained (Mason ; Sir James Paget). Measles has been 
known to result in necrosis of the hard palate and consequent perfora- 
tion ; and ulcerations of the palate, complicated by exfoliation of bone, 
occur in ill-nourished, pale, and cachectic people. Even though these 
patients improve under increasingly larger doses of iodide of potassium, 
increasing in appetite, weight, and strength to a most surprising extent, 
yet other evidences that the disease is due to a syphilitic taint are utterly ■ 
and entirely lacking. 

The results obtained in operative attacks upon acquired apertures in 
the hard palate give very little encouragement : failure is the rule and 
success the exception. It occasionally happens that after three or four 
attempts a cure is effected. As before stated, cicatricial contraction when 
the soft palate breaks down affords a fair substitution for the original 
velum, for the voice is not as much impaired by an opening in the velum 
as in the case of the hard palate. Passavant's or the Trendelenburg- 
Schoenborn operation may be tried if, the active disease being arrested, the 
cicatricial contraction is not sufficient to overcome the impairment of speech. 

Apertures in the hard palate resulting from disease or injury are best 
treated by means of apparatus. These, however, should be fitted with 
great care, for ulceration is apt to occur : it is this constant tendency to 
ulceration, in fact, which so frequently induces patients to demand, and 



174 



PLASTIC SURGERY. 



surgeons to attempt, the closure of these perforations by operation. The 
practice followed by some patients of filling these openings with mate- 
rial softened and chewed for the purpose (chewing-gum, papier machg, 
etc.) should be discouraged, as tending to enlarge the openings. The 
dentist's art should here be brought into play. 



Fig. 232. 



Rhinoplasty. 

Such destructive processes as lupus, carcinoma, and syphilis require 
plastic procedures to repair the damage caused by their ravages. Trau- 
matic defects likewise occasionally demand their performance. 

Rhinoplasty may be divided into complete and incomplete. It is also 
divided according to the location of the part from which the material for 
repair is taken. When taken from the forehead, it is known as the 
Indian or Hindoo operation ; when the skin of the arm is used, it is 
called the Italian or Tagliacotian operation ; ' when flaps are taken from 
the skin of the face, it is called the French method. Various modifica- 
tions and combinations of these are like- 
wise employed to fulfil special indications 
in individual cases. 

The Indian Method. — The operation 
of rhinoplasty became widespread in its 
application in India from the fact that 
cutting oif the nose was employed as a 
common punishment for crime. A low 
class of native priests, the Brahmins, 
usually undertook the task of repairing 
the mutilation. 

Total Rhinoplasty after the Indian 
Method.— WhiXn the total loss of all of 
the structure of the nose is very uncom- 
mon, severe lupous ulceration may re- 
quire the restoration of the tip of the 
1, space from which ^etiap from the root nosc, both alse, and the septum, and for 




2, flap from root of practical purposes this may be consid- 

nose turned down ; 3,3, nap from the __ _ _i _ . j • _ i i * i , n^i r. 



of the nose is taken ; 



iiuae Luiiitfu uuwii; 0,0, nap iroili Lue j j. 1 1 1 • 1 rr^i n 

forehead, forming new nose, sutured in ereCl aS tOtai rhinoplasty. Ihe first stage 

position over 1 and 2 ; 4, space left after ^f +i-„ „„„.,„+;„„ „ • j. • ^ i, • 

suturing defect in the foreltiead; 5,5,5,5,5, O^ ^"^ Operation COnsists lU tresheniUg 

forming ^h^fOTehia^ top °""°'''™'° ^nd broadening, as much as possible, the 

cicatricial edges of the defect, and mak- 
ing a transverse incision at the point where the new septum is to be 
implanted. In order to increase the thickness of the tissues of the anterior 
portion of the newly-formed nose, Bardeleben, Volkmann, and Hueter 
modified the original procedure by turning down a flap from the skin 
covering the root of the nose. A horseshoe-shaped incision (Fig. 232) is 
made with its convexity directed upward, the aim being to utilize as 
much as possible the integument at the root of the nose. The flap thus 

' So named from Tagliacozza of Bologna, who is generally given the credit of having 
introduced the method. Alexander Benedictiis of Padua, however, wrote upon the suh- 
ject in 1495, and Branca, a Sicilian, became famous because of the successful performance 
of the operation prior to Tagliacozza's writings. For a long time the profession was 
incredulous concerning this operation, and as late as 1742 the Faculty of Medicine of 
Paris decided that such replacement of the lost or destroyed nose was an impossibility. 



RHINOPLASTY. 



175 



marked out is dissected loose from the nasal bones and periosteum, and 
left attached near the margin of the defect. Even if considerable cica- 
tricial tissue is present, it may be used advantageously. The flap is now 
turned down (Fig. 232), its raw surface looking forward while the skin 
surface faces the nasal cavity. This portion of the procedure furnishes 
a greater thickness of flap where it is most required, and ofl^ers a firm 
foundation and broader wound-surface for the reception of the frontal flap. 
The second stage of the operation consists of the formation of a flap, 
which is properly fashioned from the skin of the forehead. The lines of 
incision to accomplish this vary. The fact should be borne in mind that 
proper nourishment must be provided for the flap, and in order to accom- 
plish this most satisfactorily it is recommended that the angular artery, 
which is the direct termination of the trunk of the facial, be included in 
the pedicle and flap. A model of pasteboard or leather may be prepared 
beforehand, and shaped, after being cut out to follow the lines of incision 
of Diefienbach (Fig. 233), Langenbeck (Fig. 234), or Konig (Fig. 235), to 



Fig. 234. 



Fig. 233. 





The older model of Dieffenbach. 



The new model of Langenbeck : 1, septum ; 2,2, 
portions to be doubled back to increase the 
thickness of the nostril ; 3,4,3,4, dotted lines 
at the points where folding back of the flap 
occurs to form double edge of nostrils. 



about the required size. Ample allowance must be made for shrinkage 
of the flap : this is of more importance than aiming at as slight a defect 
as possible in the frontal region. The latter can be closed by making, 
if necessary, incisions to relieve tension in the temporal region, where 
the hair will cover the scars. The lines of Langenbeck (Fig. 234) are to 
be preferred for the reason that the portion at 2 can be folded in on the 
line 3-4, so as to form a double edge to the new nostril. The septum 
should be made more than double the width finally required, to allow 
both for shrinkage and doubling back or hemming of its edge (Delpech). 
Septum and nostrils, by means of this device, are covered for some little 
distance, both on the intra-nasal surface and externally, with integu- 
mentary tissue (Fig. 236). 

The frontal flap must be dissected up from the periosteum. The 
edge of the knife should be directed toward the pericranial surface in 
order to avoid injury to the vessels supplying the flap. The pedicle 
must be made suiflciently long to avoid undue pressure upon the vessels 
when the former is twisted upon itself, as the flap is brought down into 
position with its raw surface looking posteriorly. As an additional pre- 



176 



PLASTIC SURGEBT. 



Fig. 235. 




Fig. 236. 




Lines of incision in Konig's rhino- 
plastic operation. 



of the flap to form 
the septum and nos- 
trils, as seen from 
below. 



caution, and to facilitate the necessary reversing of the flap surfaces, the 

incision marking the margin of the ped- 
icle should be longer upon one side than 
upon the other. The portion intended 
for the formation of a septum may reach 
to the margin of the hairy scalp. The 
forehead defect is at once remedied by 
approximating its margins as much as, 
possible ; this likewise 
seems to arrest the hem- 
orrhage (Fig. 232). The 
gap left at 4 may be 
immediately remedied 
by a skin-transplanta- 
tion strip after the 
method of Thiersch. 

Theal* and septum ^iUeTbr^hf i?^: 
are now folded so as to w^^.-^^cji margins 
appear as shown in Fig. 
236, and secured by 
means of catgut sutures. 
The latter should not penetrate the skin, but simply take in the sub- 
cutaneous cellular tissue. The flap is now adjusted to its proper posi- 
tion, and there secured by fine silk sutures. The septum is fastened to 
the upper lip, at the- incision made to receive it, by two or three sutures. 
Preliminary Transplantation of a Finyzr-tip. — As a means of pre- 
venting the depression of the tip of the nose, Hardie of Manchester and 
Sabine of New York transplanted, as a preliminary operation, the last 
phalanx of the left index finger to serve as an osseous basis of support 
to the cutaneous coverings. The method is as follows : (1) Freshen the 
.edges of the nasal opening. (2) Remove the nail and matrix of the 
finger ; make an incision upon its palmar surface as far back as the 
inter-phalangeal articulation through the integument ; dissect up the 
latter and suture it to the nasal edges. The arm, hand, and head are 
fastened immovably in a plaster-of-Paris dressing, antiseptic gauze 
serving as a dressing to the finger-end in its new position. At the end 
of four weeks the finger is amputated, and several weeks thereafter the 
usual rhinoplastic operation is performed. 

Thiersch endeavored to accomplish the same end by placing the flaps, 
one taken from each cheek, in a position to replace the septum. Wood 
recommends transplanting a portion of the upper lip for this purpose. 
Konig's procedure consists in making an osteoplastic resection of the 
outer table of the skull, which is left connected to the soft parts of the 
frontal flap, and bringing this down together with the latter. The bony 
portion of the flap is sawn through longitudinally, in order to adapt it to 
the shape of the nose. By this method the bony surface is exposed in 
the nasal cavity, and necrosis may result. If the flap is brought down, 
however, in such a manner as to turn the skin surface toward the nasal 
cavity and the bony surface outward, and the latter is covered by flaps 
taken from the cheeks (Thiersch's transplantation strips), a better final 
result may be secured. 



RHINOPLASTY. 



Ill 



Keegan's Operation. — Surgeon-major Keegan of the British East 
Indian service has communicated the following method, perfected after 
an experience in upward of forty cases.' It is only applicable to those 
cases, common in the East, in which the tip and alse of the nose are cut 
off, either by highway robbers as a mutilation of their victims or as 
an official act of punishment. 

Two converging incisions [C A, H F, Figs. 237, 238) are carried 

from two points slightly external to the roots of the alee nasi upward 

to two points about two centimetres apart on the bridge of the nose at 

the point where a pair of spectacles would rest. A horizontal incision 

Fig. 237. Fig. 238. 





Keegan's operation of rhinoplasty. 



{A F) is now made to join these two points, and this in its turn is 
bisected by a perpendicular incision (B D, E G) which follows the 
junction of the two nasal bones in the median line and stops a little 
short of their inferior borders. 

The skin and tissues are now to be cautiously dissected from off the 
nasal bones, beginning from above downward, in two flaps {A B G D 
and E F G H), which are left attached at the lines G D and G H, 
which represent the points of junction of the inferior borders of the 
nasal bones with the cartilage of the nose. As the two flaps are turned 
downward their raw surfaces present anteriorly, and their articular sur- 
faces look backward or toward the nasal cavities, the edges corresponding 
to the median line somewhat overlapping each other. This redundancy 
of tissue plays an important role in the subsequent steps of the operation. 

A flap is now taken from the forehead in the usual manner. Dr. 
Keegan has found, as the result of a large number of experiments, that 
the flap shown in Fig. 238 is best adapted, both as to size and shape, for 
the vast majority of cases in adults. The root of the pedicle occupies 
the internal angle of the eye ; the pericranium is not disturbed. The 
gap from which the forehead flap is taken is closed, before proceeding 
further with the operation, by fine sutures, in order to procure as accu- 

' Lancet, Feb. 21, 1891, p. 420. The operation of Keegan is liere given in detail, 
for the reason that it combines the best features of the various modifications of the 
Indian operation that have been suggested. 
Vol. II.— 12 



178 



PLASTIC SUBGEBY. 



rate an approximation of its edges as possible. This expeditious closing 
of the forehead defect reduces to a minimum the amount of raw surface 
to be filled in subsequently by granulation. 

A bed is now prepared for the reception of that portion of the fore- 
head flap which is to form the columna of the new nose. The flaps 
A B C D and E F G H raised from the nasal bones are reflected down- 
ward, and two triangular-shaped pieces are cut away from the redundant 
portions at the median line and transplanted to the raw surface left after 
suturing the gap in the forehead, to hasten the healing process here. 

The forehead flap is now placed in position over the nasal bones, its 
raw surface corresponding to the surfaces of the already reflected flaps 
taken from the nasal bones, as well as the surface of the latter. The 
free margins of the forehead flap and those of the nasal flap are fixed to 
each other by means of sutures. The columna is formed by fixing the 
portion marked A in the bed already freshened to receive it by sutures. 
Some fashioning and trimming will now be necessary. The two 
original incisions {C A, H F) are to be deepened and bevelled, and into 
these are to be secured by sutures the lateral margins of the forehead 
flap. Short drainage-tubes are placed in the newly-formed nostrils, 
which are lined inside with the skin-covering of the reflected nasal flap. 
Lint and boracic-ointment dressings are applied. The drainage-tubes 
are removed in ten days, and the pedicle of the new nose is divided at 
the end of a fortnight. 

OUier's Operation. — This operation is intended to supply the loss of 
the alse, columna, cartilages, and a portion of the septum. The disease 
(lupus) in the case for which the operation was originally designed had 
extended to the integument of the lip and cheeks, and these could not 
be utilized in the formation of flaps. Two diverging incisions, com- 
mencing in the median line of the fore- 
head two inches above the eyebrows, 
were carried downward to within one- 
fourth of an inch from the outer side of 
the nasal orifice (Fig. 239). The trian- 
gular flap thus formed included at its 
upper portion the periosteum to the root 
of the nose. The dissection was carried 
along the right nasal bone, and did not 
include the periosteum, but the remains 
of the cartilage at the latter point were 
detached and remained attached to the 
flap. An osteoplastic resection of the 
left nasal bone was now done, the bone 
being separated by means of a chisel and 
left attached to the left half of the flap. 
The cartilaginous septum was then di- 
vided from before backward and down- 
ward with scissors, and left attached by 
its base to the cutaneous cartilage to 
form a central support for the new struc- 
ture. The entire flap, including the periosteum from the forehead over 
the frontal sinuses, the resected left nasal bone, the divided cartilaginous 



Fig. 239. 




OUler's method of rhinoplasty. 



RHINOPLASTY. 179 

septum, and the soft structures overlying all these parts, was now drawn 
downward until the upper border of the loosened left nasal bone came 
opposite the lower border of the right one, where it was secured by a 
wire suture. The sides of the flap were then united to the cheek, and 
the gap in the frontal region closed by sutures. The space left by the 
removal of the left nasal bone is said to have been filled in, in Ollier's 
case, by bone developed from the periosteum that had been slid down 
from the forehead. 

Wood's Operation. — The new nose is formed from a broad flap taken 
from the upper lip, the latter being split in a direction parallel to its 
plane surface in such a manner as to free it of both its cutaneous and 
its mucous layers, and this separation extending to but not through the 
vermilion border. The flap thus obtained consists of that portion of 
the substance of the upper lip lying between its cutaneous and mucous 
surfaces, which, after being turned upward, was fixed by sutures to the 
previously-freshened upper margin of the defect ; its raw surface is 
closed in by a flap taken from the cheek of either side. The plan of 
building up a new nose by tissues derived from the upper lip has never 
found favor with surgeons, for the reason that these tissues are very 
unstable, and but an indifferent result is obtained at the best. 

After-treatment in Total Rhinoplasty from the Frontal Re- 
gion. — The hemorrhage is quite profuse, although not sufficiently so to 
involve danger to life. Repair of the frontal defect now takes place, in 
part by first intention and in part by granulation. Failure of the former 
over the exposed periosteum sometimes leads to necrosis, but this rarely 
separates, the granulations from the diploe gradually taking the place of 
the necrotic tissue. The cicatrix which finally forms, as a rule, does not 
produce marked deformity. 

Grangrene of the newly-formed nose is not common. Sensation in 
this part is at first referred to the forehead ; this changes later on. Care 
must be taken to maintain the nasal apertures patent : there is consider- 
able tendency for these to contract. Tampons of antiseptic gauze are 
employed to prevent this at first, and later on metal tubes are introduced. 
These should be worn at night for some time afterward. Sufficient nor- 
mal mucous membrane usually remains to maintain the sense of smell. 
The pedicle should not be divided, but after some months, if sufficient 
elevation remains to constitute a deformity, portions may be excised. 

The Elevation of the Tip of the Nose. — The subsequent depression of 
the tip of the newly-formed nose sometimes requires measures of correc- 
tion secondarily. Langenbeck attempted this by sawing strips of bone 
from the lateral walls and bending them so as to serve as rafters of sup- 
port for the nose. The attempt rarely proves successful. Hueter split 
the tip of the nose, drew apart the edges of the incision so as to form a 
V-shaped cavity, and transplanted into this a portion of the integument 
from the plantar surface of one of the toes. 

Frames of gold, platinum, and lead have been resorted to to maintain 
the tip of the nose in position, with varying degrees of success. As a 
rule, they are finally abandoned on account of the irritation which they 
produce. Leisrink successfully employed a light frame of yellow amber, 
upon which the frontal flap was placed. Celluloid may prove, upon trial, 
usefiil for this purpose. 



180 



PLASTIC SURGERY. 



Partial Ehinoplasty. — Dieffenbach declared that rhinoplastic 
operations are the more difficult the smaller the parts to be restored. 
The skill of the surgeon will be taxed to its utmost in taking proper ad- 
vantage of the conditions as they present themselves. Strictly speaking, 
almost any rhinoplastic procedure is partial ; whatever remains of the 
original nose, whether of alae or septum, is to be carefully preserved under 
all circumstances. 

Reduction or Replacement of Displaced Ala. — Cicatricial inward dis- 
placement of an ala is rather a frequent sequence to syphilis. The ala 
should be loosened by means of the knife, placed in correct position, and 
united with a frontal flap, while kept in proper shape by tampons, etc. 
The shape of the frontal flap must be modelled to suit individual cases. 

Sunken Nose. — Diefi^enbach recommends the following method : The 
skin of the sunken nose is separated in the median line, and an oblong 
flap from the frontal region implanted between the wound-edges. After 
healing, both halves of the nasal skin, which have been pushed to either 
side in order to unite with the flap-edges, are dissected loose from the 
edges, separated as far as necessary, even upon the cheeks, brought 
together in the median line, and sutured together over the freshened 
frontal flap. 

A modification of Dieffenbach's operation consists in bringing down 
the frontal flap in a reverse manner — i. e. turning the skin surface so as 
to look toward the nasal cavity, and immediately suturing the lateral 
skin-flaps over the raw surface, now uppermost. 

Verneuil's Operation. — This operation was suggested to M. Verneuil 
by M. Oilier for a case in which the patient had discharged a pistol in 
his mouth, destroying a portion of the hard palate and septum, the nasal 

bones, part of the nasal processes of 
Fig. 240. ^q superior maxillae, the spine of 

the frontal, and the anterior wall of 
the frontal sinuses. As a result of 
this, the parts were greatly sunken ; 
the alse and tip were uninjured, al- 

FiG. 241. 





Verneuil's method of rhinoplasty : the 
lines of incision. 



Verneuil's operation of rhinoplasty 
for sunken nose. 



though much flattened (Jacobson). A vertical incision was made along 
the median line of the depressed organ, and a transverse one at each end of 



RHINOPLASTY. 



181 



this (Fig. 240). The two flaps thus marked are dissected up and tTirned 
back. An oblong flap is now raised from the middle of the forehead and 
left adherent between the eyebrows. This is now turned (not twisted) 
downward, its skin surface being turned toward the nasal cavity, and 
fixed in position by a few sutures. The two lateral flaps previously dis- 
sected up are now drawn over the ra\v surface of the frontal flap and 
united by sutures in the median line (Fig. 241). The wound in the 
forehead is closed as fiir as possible, and any granulating surface left 
subsequently skin-grafted. The pedicle of the frontal flap is divided 
and trimmed at a later period. 

Jacobson modified the procedure for a case in which the nose had 
been extensively destroyed by the combined effects of lupus and a quack 
ointment and plaster, but in which the bony parts were almost intact, by 
refreshing the skin surface of the forehead flap before placing it in 
position.' 

Saddle Nose. — F. Koenig's method consists in separating the cartilag- 
inous from the bony portion of the nose by a transverse incision, restor- 
ing the shape, and filling in the defect by means of an osteoplastic flap 
taken from the frontal region. The latter is reversed in turning it down- 
ward in such a manner as to p)lace the skin facing posteriorly, in toward 
the nasal cavity. A second frontal flap is dissected up and brought 
down, with its pedicle twisted in the usual manner, and placed over the 
first. The two raw surfaces thus come together. The flaps are sutured 
in position separately. Final trimmings and corrections of shape are 
matters of after-treatment. 

Formation of Ala of Nose. — This is usually required to correct the 
ravages of carcinoma. Langenbeck operated as follows : A quadrangu- 
lar defect remaining, following extirpation of the right ala, a rectangular 
flap of skin, left attached near the root of the nose, is dissected from the 

Fig. 243. 



Fig. 242. 





Langenbeck's method. 



DenonviUier a method. 



lateral surface and ala of the left side, brought over to cover the defect, 
and sutured in place (Fig. 242). Care should be exercised in dissecting 
the skin from the remaining ala, to which it is closely attached, that the 
perichondrium is not injured on the one hand, nor the flap button-holed 
on the other. The surface from which the flap is taken heals over by 
granulation. The final result is sometimes excellent. 

' Operative Surgery, p. 256. 



182 PLASTIC SURGERY. 

Denonvillier's Method. — In this operation a triangular flap with 
a pedicle is dissected from the sound tissues of the nose above the 
defect. An incision is made, commencing from near the tip of the nose 
and toward the sound side, and is carried upward nearly to the root (a b, 
Fig. 243). A second incision, commencing at the upper termination of 
the last named, descends obliquely downward (6 c), and terminates at 
the upper and outer angle of the defect of the ala. This flap should be 
so arranged that when dissected up the pedicle or lower portion should 
contain a section of normal cartilage from the tip of the nose. 

Weber's Operation. — In this operation the formation of a new ala is 
accomplished by cutting an oval flap from the centre of the upper lip, 
the pedicle of which is left attached at the columna : the free margin 
reaches to the prolabium ; only a part of the thickness of the lip is 
utilized in the flap. The flap is turned upward and sutured in position 
to the margins of the defective ala, which have been previously fresh- 
ened. The pedicle is divided at the end of three or four weeks, and is 
applied to the inner surface of the flap, so as to give a thicker and rounder 
margin to the new ala (Treves). 

Total Rhinoplasty from the Aem. — Italian Method. — This 
operation is rarely performed at the present time. An exact imitation 
of the nose and septum cannot even be approximated, and at best 
a cicatricially shrunken mass of skin is implanted in the region of the 
nose. The excessively awkward, and even painful, position of the arm 
cannot be borne, and, save in very rare and exceptional cases, the pro- 
cedure is practically abandoned. 

Tagliacozza's Operation. — This consists, essentially, in making two 
parallel incisions over the middle of the biceps muscle, and dissecting 
up the skin between these, thereby obtaining a flap of skin attached by 
a pedicle at either end. Dressings are packed beneath this, and at the 
end of a week, when granulations have formed upon the posterior sur- 
face, the upper pedicle is separated. The flap is now permitted to 
shrink still more, in order to thicken and assume somewhat the shape 
of a nose, when, at the end of the third week, it is implanted into the 
defect. The arm is brought into position, and there maintained for eight 
days, at the end of which time, vascularization from the facial skin being 
completed, the remaining pedicle is separated and the arm released. 

Von Grdfe's Modification. — This is the so-called German method. 
It shortens the time of the operation, but this is no particular advantage, 
for the reason that the most trying part of the procedure to the patient, 
the position of the arm, remains as before. The modification consists 
in making but one pedicle and implanting the flap at once. 

Tlie French Method. — This is preferable to the Italian method or 
that of Tagliacozza : the latter should be employed as a last resort only. 
The surgeon should be familiar with both, however, in addition to the 
Hindoo operation, or that of taking the flap from the forehead, for the 
reason that lupus and syphilis may destroy the skin of the forehead.^ 

Plastic Operations upon the Septum. — The septum is rarely 
destroyed by syphilis without simultaneous involvement of the ala. In 

' Even under these circumstances Langenbeck recommends separating the cicatricial 
skin tissue and periosteum, and forming a flap thereby. The success of such a procedure 
must be very doubtful indeed. 



SYNDACTYLISM. 183 

those rare cases in which it becomes necessary to rstore the septum ex- 
clusively, one of the following procedures may be resorted to : 

The Italian Method. — This method is not frequently employed at the 
present day. It consists in dissecting a flap from the palmar surface of 
the hand, instead of from the arm ; the rest of the procedure is similar 
to that employed in total rhinoplasty from the arm. 

Dieffenbach's Method. — This method consists in removing a portion 
of the upper lip throughout its entire thickness, and reversing it in 
placing it in position : the mucous membrane soon becomes hardened 
by exposure to the air, so as to resemble skin. It does not form a very 
firm support to replace the septum, and in females, who cannot grow 
a moustache to cover the lip deformity, the improvement is not sufficient 
to compensate for the latter. 

Hueier's Method. — In accordance with the principles of Langenbeck's 
operation for restoring the ala of one side by implantation of the skin 
covering that of the opposite side, Hueter advised the formation of 
a septum from the skin covering the bridge of the nose. The flap is 
shaped in a somewhat oblique direction, which facilitates its rotation 
into position from the tip of the nose toward the lateral wall. The 
upper portion of the flap may include the periosteum, a more substan- 
tial support resulting. The rotation of the pedicle, occurring at the 
very tip of the nose, seems to assist in elevating this portion, which is 
usually considerably sunken by the loss of the septum. 

Syndactylism. 

Bridges of tissue are sometimes developed between two fingers, form- 
ing a lateral union by means of soft parts or, more rarely, cartilage. 
The most common form encountered is that in which integumentary 
tissue alone forms the medium of union, and is known as icebbed fingers. 
The deformity is either congenital or acquired. The congenital cases 
are due to an arrest of the process that deepens the grooves between the 
tubercles which represent the site of the fingers in the rudiment of the 
hand in early fcetal life. The acquired cases are those of cicatricial 
webbing caused by burns. Here the web is very short and thick. 

The web may be partial or complete, in the former extending to or 
slightly beyond the interphalangeal joint, or the fingers are united to 
near their tips. The fingers may be closely united by a short web, or 
the latter may be sufficiently long to permit of some freedom of motion. 
The fold of skin forming the web in the membranous variety has its 
base, which is usually concave, toward the free ends of the fingers, and 
its apex at the interdigital space. A slight increase in the interdigital 
fold, not sufficient to constitute webbed fingers, is sometimes observed, 
and gives the hand the appearance of having very short fingers. 

The inner fingers are most commonly united, particularly the ring 
and little fingers. Any of them may be joined, however, although it is 
very rare to find a thumb united to the index. 

Treatment. — Where the web is such as to closely unite the fingers 
the functional disability is an indication for operative interference. 
Even where the web is sufficiently loose to permit of considerable motion 
the deformity is unsightly and treatment is demanded. The methods of 



184 



PLASTIC SUnOEBT. 



operation formerly practised, such as simple division of the web by the 
knife or scissors, were followed by recurrence, the cicatricial tissue com- 
mencing at the apex of the triangle between the separated fingers and 
reuniting the latter. Slow separation by the wire 6craseur, Maison- 
neuve's clamp (which resembles in its action Dapuytren's enterotome), 
and Lister's method by the elastic ligature give equally unsatisfactory 
results. 

Operation by a Permanent Opening at the Base of the Web. — Eud- 
torffer formed a cicatricial opening resembling the ear-ring opening in a 
woman's ear. He employed a lead button for the purpose of maintain- 
ing the patency of the opening until cicatrization was completed, after 
which the bridge of skin was divided for the remainder of its length. 
The after-treatment consists in keeping the fingers well apart by the 
interposition of dressing materials. A silver or gold ring may be used 
instead of the lead button. One end of the ring may be sharp and the 
other hollow, and the two ends fitted together after introduction. 

Didot's Operation.^-Didot's operation consists in an attempt to obtain 
palmar and dorsal flaps of skin with which to cover in the wound sur- 
face of each finger after separation. The separation is effected in such a 
manner as to obtain two longitudinal flaps, which are dissected up as 
thick as possible, the one from the palmar and the other from the dorsal 
aspect of the affected fingers. An incision is made along the middle 
of the palmar surface of one finger, and is joined at each end by short 
transverse incisions to form a flap. A similar proceeding is carried out 



Fig. 244. 



Fig. 245. 



Fig. 246. 






Didot's operiition for webbed fingers. 

on the back of the other finger. Two flaps are thus obtained, and at 
the same time separation is effected. Each flap is then folded round to 
cover in the raw surface of the finger to which it is attached, and secured 
by fine sutures. (See Figs. 244, 245, 246.) 

I have encountered two obstacles to success in this plan of opei'ation. 
First, in membranous web-fingers the substance of the web is not suffi- 
cient to permit of the necessary splitting to form the flaps without impair- 
ing the nourishment of the latter. Second, in spite of the most careful 
watching, commencing recontraction at the interdigital cleft may lead to 
recurrence. Special precaution is required, as pointed out by Annandale, 



SYNDACTYLISM. 



185 



Fig. 247 



to avoid interference with the functions of the fingers by making the 
flaps too broad. Encroachment upon the palmar and dorsal surfaces by 
the incisions will lead to impairment in the one of flexion, and in the 
other of extension, by cicatricial formation. 

Dec's Operation. — This operation may be practised in cases where a 
large web exists. A fold of skin is raised by the aid of a mouse-toothed 
forceps near the base of the web and dissected toward the commissure. 
The fingers are kept well apart, and on cicatrizing the tongue of skin 
formed from the base of the web retracts and forms a new commissure. 

Norton's Operation^ (Fig- 247). — This operation is carried out some- 
what upon the lines of Dec's, but is an im- 
provement upon the latter. Small triangu- 
lar flaps are raised at the clefts on the dorsal 
and palmar aspects. The webs are then 
divided, all tissues being thoroughly severed 
up to the bases of the flaps, which are then 
carefully joined together at their apices with- 
out tension. Every effort must be made to 
effect rapid union. The flaps should be 
thick in order to ensure a proper blood-sup- 
ply, sufficiently long to prevent tension when 
united, and somewhat narrow to prevent 
bulging. Any tissues between the knuckles 
should be removed to let the flaps come well 
together. The apices of the flaps in young 
children are very small, and a fine needle 
should be used in the suturing. In arrang- 
ing the position of the flaps care should be 
taken to observe the natural line of the web. 
kept well apart during the healing process. 

Agnew's Operation. — " A V-shaped piece is cut from the dorsal sur- 

FiG. 248. FiO. 249. 




Norton's operation. 



The fingers should be 





Agnew'a operation, showing the flesh taken from 
the dorsal surface of the web and attached to 
the palmar surface after division of the web. 



The incisions in Zeller's operation. 



face of the base of the web, the apex anterior. The flap, which 
1 British Medical Journal, 1891, vol. ii. p 931. 



186 



PLASTIC SURGERY. 



extends through one-half the thickness of the band, is next dissected 
back, and the remaining portion of the web slit longitudinally. The 
reflected flap is then drawn through the cleft at the base of the fingers, 
its apex stitched to the palmar surface of the wound, and its sides to the 
adjoining sides of the fingers (Fig. 248), at the same time closing the 
edges of the wound on each side of the fingers, keeping a strip of oiled 
silk between the fingers, and supporting the hand on a palmar splint." ' 
This operation is almost identical with that next to be described. 

Zeller's Operation. — Two incisions are made upon the dorsal aspect 
of the web and fingers, extending from the metacarpo-phalangeal to 
the first interphalangeal joints (A B, Fig. 249). The triangular flap 
thus obtained is dissected toward its base, and the remainder of the web 
is divided (C D). The fingers are now held well apart, and the reflected 
flap {E) is placed betweeti the cleft and fixed by sutures to the palmar 
surface of the hand. The raw surfaces {G) are kept well apart by 
appropriate dressings. The union of the surface of the flap to that of 
the cleft obviates the tendency to contraction. 

Fowler's Operation. — Finally, in cases in which failure has resulted 
from former operations, and considerable dense cicatricial tissue has re- 
placed the original web, I have succeeded by dissecting up two narrow flaps 
from the back of the hand, and passing these through a buttonhole-like 
slit previously made in the line of the natural web and well up between 
the heads of the metacarpal bones (Figs. 250, 251). The flaps should be 
placed with their skin surfaces facing each other. Each flap is slightly 
rotated upon itself in order to pass through the buttonhole, and is made 



Fig. 250. 



Fig. 251. 





Showing site of button-hole slits, A^, A', and 
lines of incision, B^, B', B', for the forma- 
tion of the flaps. 



The flaps, A, A, passed through the slits, and 
the gap from which the flaps were taken 
closed by a line of sutures, B. 



Fowler's method of operation for webbed fingers. 



sufiiciently long to project a quarter of an inch or more upon the palmar 
surface, to allow for contraction. No sutures are required to retain 
these in position. The projecting ends upon the palmar surface are 
transfixed with a needle or hare-lip pin, and aseptic dressings applied. 
After a week the web is divided, when it will be found that the 
' Agnew's Surgery, vol. iii. p. 371. 



POLYDACTYLISM. 187 

interdigital cleft is occupied upon either side by healthy integumentary 
tissue, which effectually prevents this from becoming the starting-point 
for reunion. Keeping the fingers separated by a layer of oiled silk, and 
careful aseptic after-treatment will ensure a good result. The method 
is equally applicable as a primary procedure. In case two webs are 
present to be dealt with, a slit should be made above the apex of each 
web, and one flap passed through each. Under these circumstances but 
one side of the cleft is lined with skin tissue, but this is ordinarily suffi- 
cient to prevent recontraction. 

When the flaps are well attached the pedicles are to be divided. 
This may usually be done at the time of division of the web. The gap 
from which the flaps were taken, however, may be closed at once or at 
the first stage of the operation. 

Supernumerary Fingers, or Polydactylism. — This is not of 
very uncommon occurrence and may be hereditary. Three forms are 
usually observed : (1) The supernumerary digit is rudimentary, may con- 
tain some cartilage, and is attached by a pedicle to one of the fingers or to 
the head of one of the metacarpal bones ; (2) a fully-formed digit may ar- 
ticulate with the articular extremity of one of the phalanges, ,or with one 
of their lateral surfaces, or with a metacarpal bone ; (3) a complete digit, 
with or without a separate metacarpal bone, may be joined to the entire 
length of a finger. If one metatarsal bone answers for both, the super- 
numerary digit articulates conjointly with its neighbor, and one capsular 
ligament and joint-cavity serves for both. Polydactylism is apt to occur 
in both hands, and symmetrically in the feet. 

Treatment. — Supernumerary fingers are best dealt with by removal. 
There can be no question as to the propriety of this in the first two 
varieties ; in the third surgeons were loath to operate because of the 
interference with the joint, and it was therefore thought best to ampu- 
tate the extra digit distal to the articulation. The dangers of opening a 
joint having been reduced to a minimum by aseptic measures, this plan 
has been quite uniformly rejected, because of the unsighly stump which 
it leaves, and the supplemental finger (or toe) is removed entirely. 

Congenital Deficiencies. — ISTumerical deficiencies, as well as those of 
size, are here included. One or more fingers may be missing, with or 
without absence of the corresponding metacarpal bones. Deficiencies of 
size are usually due to an absence of one or more of the phalanges of a 
finger. Congenital amputations are also included in this class. The 
treatment consists in amputation if the imperfectly developed finger be 
useless or in the way. 

Congenital Hypertrophy of one or more digits may occur. This has 
been described by H. Fischer under the name o? " giant finger." The 
increase in size may be due to an excessive development of any of the 
tissues or only of the subcutaneous connective and fatty tissues. Rarely 
a single phalanx is involved. Giant hands and feet are features of the 
disease known among neurologists as acromegaly, or Marie's disease, 
which has been supposed by some to depend upon enlargement of the 
pituitary body. 

Treatment. — Treatment by pressure bandages is useless, as when they 
are removed the growth is almost certain to relapse. Amputation may 
be resorted to if but a single finger is involved and this is in the way or 



188 PLASTIC SVRGERY. 

unsightly. If several fingers are involved and the affection partakes of 
the nature of elephantiasis, ligation of the main artery of the limb may 
be tried. 

BONE-GBAFTING. 

The views formerly held that pieces of bone which were completely 
removed from their surroundings and then replaced or implanted in a 
distant part retained their vitality, and even underwent proliferation, are 
now known to be erroneous. The transplanted bone merely forms a scaf- 
folding in the substance of which, after partial or complete decalcification 
has talien place, infiltration of bone-forming cells takes place. A. Barth 
of Marburg' in a series of experiments upon animals found that although 
bone thus transplanted became either encapsulated with fibrous tissue or 
healed in by osseous union, death of the fragment took place invariably. 
The replacement of the old bone by new does not take place by absorp- 
tion of the former and subsequent growth of the latter, but a process of 
gradual substitution of living for dead bone, in which the osteoblasts 
penetrate directly into the substance of the bone, takes place. 

Eeplacembnt of Bone after Trephining. — The question of re- 
placement of buttons or fragments of bone after trephining has been 
settled in the affirmative. Numerous observers have recorded their ex- 
periences, and these have been, on the whole, favorable. The pieces 
upon removal are placed immediately in an aseptic salt solution until the 
stage of the operation is reached at which they are to be replaced. If the 
wound is an accidental one, the fragments removed are more or less cov- 
ered with foreign matter, hair, etc. These must be washed thoroughly, 
and further cleansed, if necessary, by scraping with a bone-chisel or 
scalpel. They are then disinfected by means of a weak mercuric-chloride 
solution, and finally washed in an aseptic salt solution before replacement. 
If only a small amount of bone has been saved, the pieces are to be laid 
upon an aseptic surface and chopped into small fragments. These are to 
be evenly distributed over the dural surface. 

Bone-implantation in Defects of Long Bones. — "When a defect 
in a long bone whose continuity has been destroyed exists, the attempt 
is sometimes made to supply this by properly-shaped bone-grafts or 
bone-chips taken from a recently-amputated limb or removed from 
a living animal. In ununited fractures and shortening from loss of 
bone-substance the ends of the bones are freshened preliminarily, and 
a proper sulcus or groove prepared in the tissues between the frag- 
ments. 

The chances of success in the latter class of cases are small. The 
causes, intrinsic in the bone itself, which prevented union of the original 
fragments will be almost certain to prevent union between the implanted 
and original bone. 

Sliding Operations. — These consist of attempts to fill in defects 
of bone by either displacement of a bony part in its entirety — such, for 
instance, as dividing M'ith the chisel a strip of hard palate with its 
coverings parallel to the fissure in cleft-palate, and crowding this over 
to the median line, and there securing it to a similar bony flap prepared 

' Verhandlunr/m der deuischen Gesellschaft fiir Chirurgie, Arinl 12,1893; Centralblall fur 
Chirurgie, July 29, 1893. 



BONE-GRAFTING. 189 

in the same manner from the opposite side — or a layer of bone may be 
separated and transplanted with its entire skin-covering, as, for instance, 
from the frontal bone in forming a new nose (Konig). J. Wolff' pro- 
posed to fill in bony defects by separating a layer from the neighboring 
bone and sliding it into the defect by means of the loose fibrous con- 
nection between the periosteum and skin. Wolff reports, among others, 
three successful operations for " saddle nose " by this method. Curtis 
employed a similar procedure successfully in a case of defect of the 
tibia following compound fracture and necrosis. In this case the 
desired length of bone to fill the gap was obtained from the fibula in 
several pieces, owing to its having been previously fractured. The 
pieces were pushed through an opening made between the muscles and 
inserted in the gap in the tibia.^ 

Elongation of the ligamentum patellae has been successfully treated 
by subcutaneous transplantation of the tubercle of the tibia, wdth the 
attached tendon, to a point lower down on the bone.^ In old cases of 
fracture of the patella, in which shortening of the ligament prevents 
proper replacement of the lower fragment in the operation of wiring, 
tlie tubercle may be displaced in an upward direction by a similar 
method of transplantation (Volkmann). 

BoNE-GEAFTiNG BY DECALCIFIED BoNB. — This method, devised 
by N. Senn, consists in the implantation of bone-chips and bone-plates, 
previously decalcified, in aseptic bone-cavities and defects left by 
trephining. 

Preparation of the Bone. — The compact layer of the fresh tibia or 
femur of the ox is used for the purpose. The periosteum and medullary 
tissue are removed, and the bone is sawn into longitudinal strips about 
an eighth of an inch thick. These strips are immersed in a liberal 
quantity of a 10 to 15 per cent, solution of hydrochloric acid in water, 
which must be renewed daily for from one to two weeks. They are 
then to be washed thoroughly in water or a weak alkaline solution, 
immersed for forty-eight hours in a 1 : 1000 mercuric-chloride solution, 
and finally placed for permanent preservation in a saturated solution 
of iodoform in ether. The pieces intended to be used as bone-chips 
should be cut into small pieces before immersing in the sublimate 
solution. 

When the bone-grafts are to be used the pieces selected for the opera- 
tion are wrapped in aseptic gauze and immersed in alcohol to dissolve 
out the ether and iodoform. They are then immersed in a 1 : 1000 
mercuric-chloride solution, and just before being placed in position they 
are to be carefully dried with iodoform gauze. 

Preparation of the Cavity or Defect — Tlie cavity or defect is to be 
thoroughly cleansed by curetting, and sterilized by repeated flushings 
with a 1 : 2000 solution of mercuric chloride,* scoured by means of 
aseptic gauze, and finally dusted carefully with iodoform. H. Dreesmann 
of Bonn secures asepsis by filling the cavity with olive oil into which is 

' Deutsche medizinal Zeitung, Berlin, June 5, 1893. 
' Am. Journal Medical Sciences, July, 1 893, p. 30. 
' Walaham, Bntish Medical Journal, Feb. 18, 1893. 
* Deutsche medicinische Wochenschrift, May H, 1893. 



190 PLASTIC SUROEBY. 

plunged the glowing point of a thermo-cautery, thus bringing the oil to 
the boiling-point. 

Filling the Cavity or Defect. — The cavity or defect is now to be 
filled in with the bone-chips or plates. In case an irregularly-shaped 
cavity is to be filled, the bone-chips are packed in carefully until the 
gap is filled. A capillary drain is placed at the most dependent point, 
and the periosteum and soft parts are united with buried animal sutures. 
If a defect of the soft parts is present, an iodoform-gauze compress is 
placed over the defect to hold the bone-chips in position. 

In cases of openings or gaps in the skull, these are to be filled with 
plates cut from decalcified bone to fit. These should be perforated to 
facilitate drainage. 

The superiority of the method of bone-grafting by means of decalci- 
fied bone over that of completely detached bone has been attested by 
instances in which cavities have been treated by the simultaneous implan- 
tation of decalcified bone and fresh fragments of bone from the patient's 
own body. Not only have the former been found to be superior for 
this purpose, but the latter, it is believed, actually hinder the healing 
process.' 

1 A. G. Miller, Laiwet, Sept. 20, 1890. 



MILITARY SURGERY AND THE CARE OF 
THE WOUNDED ON THE BATTLE-FIELD. 

By Lt.-Col. W. H. FORWOOD, 

Deputy Sukgeon-General U. S. Army. 



I. New Conditions arising feom the Introduction of Aseptic 
Surgery and Modern Firearms. 

Since the close of the last great war among civilized nations a change 
has taken place, no less radical and complete in surgical methods than in 
the character and efficiency of military weapons. The old treatment of 
wounds and the technique of operations have been revolutionized by 
the discovery and general application of antiseptic principles, while in 
the mean time the old lead small-arm bullet, which has made the vast 
majority of the gunshot wounds in all modern wars, and with the effects 
of which military surgeons are so familiar, has been replaced by another 
totally different missile of great but still uncertain capabilities. The 
grand results which have been achieved through recent improvement in 
general surgery are well known. What effect the introduction of the 
new weapons will have upon the character of gunshot injuries and on 
the care and handling of the wounded is not yet fully determined. The 
experience and the literature accumulated during former wars are based 
almost wholly upon the results of the old surgery with the old weapons 
now obsolete. 

The effects of the new infantry rifle projectile on animate and inani- 
mate objects have recently been the subject of most elaborate study 
by surgeons in this country and abroad. Experiments on the cadaver 
show the mechanical action of the new projectile on dead and more 
or less deteriorated animal structures, as well as the effect of these 
structures on the stability of the bullet ; but there are many import- 
ant questions of the utmost interest to the military surgeon upon which 
they can give no evidence. The tearing and mangling produced upon 
decayed muscles and putrid viscera can hardly be the same as upon 
those organs in the living state. The flaccid and inelastic condition of 
dead skin must certainly have an influence on the size and appearance 
of wound-openings. Experiments on the cadaver furnish no evidence 
as to the percentage of mortality, immediate or remote,, in any class of 
injuries, nor as to those important factors in gunshot wounds, shock and 
hemorrhage, nor of the results of treatment, the occurrence of suppura- 
tion or of septic£emia. 

It is evident from present indications that the small-calibre bullet, 
which must eventually be adopted among all nations, will be one 
which is practically indeformable against animal structures and almost 

191 



192 MILITARY SURGERY AND THE CARE OF THE WOUNDED. 

identical in ballistic qualities — alike in form, weight, calibre, and 
velocity, and alike for the rifle, the carbine, and the machine-gun. 
The factors which enter into the causation of gunshot wounds from 
these missiles will thus be so constant and uniform as to produce 
far more constant and uniform results than have been observed with 
the old deforming lead bullet. The difference between these two, as 
stated by Delorme and Chavasse, lies mainly in the greater force of 
penetration, greater stability, and smaller diameter of the former. There 
can be no doubt that the new bullet will exert a more definite effect on 
the tissues than did the old, whether more fatal in the long run or less. 
There will be fewer doubtful cases. The great difficulty in determining 
the prognosis of gunshot wounds made by the old bullet was the uncer- 
tainty as to what complications might exist. Even when the wounds of 
entrance and exit were clearly marked, there could be no assurance that 
a part of the lead, or pieces of the clothing or other foreign matter were 
not left concealed in the tissues. That the small-calibre bullet rarely 
remains in the body when fired from any distance within the effective 
range of the rifle, that it rarely deforms even on impact against resist- 
ing bone, and rarely carries clothing or infectious material into the 
Avound, are new features of the greatest importance to the surgeon and 
the patient. 

As the modern rifle projectile has a greater velocity, a flatter trajec- 
tory, and consequently a wider range within the ordinary height of a 
soldier than the old, and as it is capable of penetrating the human body, 
or even five bodies in a direct line, without regard to the structures 
intervening, as shown in the experiments of Bruns and others, and as 
a greater number of the small cartridges can be carried in the belt 
and fired with greater accuracy and rapidity than formerly, it may be 
assumed that there will be a greater number of men wounded on the 
battle-field within a given time in future Avars than have been in the 
past. Tactical changes must be made to meet the neAv conditions. 
Lines of battle Avill no doubt be greatly extended, distances on the field 
Avill be vastly increased, and the wounded Avill in consequence become 
Avidely scattered. Engagements will open at longer ranges, and, Arith 
the use of relatively smokeless powders, they will proceed Avith greater 
accuracy of aim and more destructiA-e effect. Battles will be shorter, 
sharper, and more decisiA^e, and campaigns AA'ith all their disastrous con- 
sequences of sickness from camp and epidemic diseases will be less 
prolonged. 

The ratio of killed to wounded appears likely Avith the ncAV weapons 
to be increased. The long, clean cut, non-contused tracks of the small- 
calibre bullet favor internal hemorrhage, one chief cause of mortality 
in the field. But, on the other hand, for those AA'ho sur\-ive the imme- 
diate effects of their injuries these Avounds, with their small valve-like 
openings that readily close, are also favorable to healing, and thus the 
ratio of recoveries to the number of Avounded Avill likewise be increased, 
Avhile the percentage of secondary mortality and the number of per- 
manently crippled AA^ill be reduced, both through the more faA'orable 
character of injuries by the ncAA^ projectile and through the new aseptic 
methods in surgery. 

Much stress has been laid upon the effect AA'hich the long range of 



FIELD ORGANIZATION. 193 

modern firearms is expected to have upon the facilities for removing the 
wounded from the field. Professor von Bardeleben has recently said, 
in substance : " The first and most difficult task will be to remove 
without delay the enormous number of wounded out of the fire-line. 
Who will be able to tell beforehand where bandaging-places will be out 
■of reach of the enemy's fire? Some urge an increase of sick-bearers 
and wagons, but this also increases the number liable to be wounded, 
and in order to effect an uncertain saving of one human life exposes the 
lives of a number of other men to danger." Battles are rarely fought 
on level, unobstructed plains ; distances therefore between the line of bat- 
tle and the dressing stations or field hospitals are not measured in yards ; 
they are determined by the physical and topographical features, natural 
and artificial, of the region in rear of the battle-field. These may some- 
times be very favorable, or they may be in the highest degree unfavor- 
able, to the care and removal of the wounded. Ambulance wagons can 
only be brought to the front under cover of some natural object which 
may offer protection against artillery and infantry fire ; otherwise the 
injured, unable to walk, must remain in sheltered places until oppor- 
tunity offers for their removal. It will be quite impossible with any 
reasonable number of bearers to carry the usual proportion of seriously 
wounded from the field on litters to a point beyond the reach of modern 
artillery field or siege rifles, since these weapons are capable, with the 
new powders, of exploding shells with considerable accuracy against 
visible objects at a distance of from three to five miles. This seems to 
indicate the necessity for plenty of surgeons and attendants at the 
various collecting stations or nearest places of safety where the wounded 
may be held and cared for during the prevalence of the " traumatic epi- 
demic " of battle, and perhaps for some time after. It has been sug- 
gested by eminent authority that under the new conditions, plans for 
the immediate removal of the wounded from the field should be given 
up and efforts made to provide temporary hospital accommodation for 
them in such places as may be practicable near at hand. 

n. Field Organization. 

A well-organized system for rendering prompt aid to the wounded on 
the field now forms part of the military establishment of every civilized 
nation. These systems are identical in principle and differ only in mat- 
ters of minor detail. The original prototype of all is to be found in the 
" ambulance volante " of Baron Larrey, which Napoleon said was " the 
happiest conception of the age," and in the brancardiers of Baron 
Percy. 

The organization maintained in time of peace is so constructed as to 
be capable of expansion and readjustment to meet the necessities of war. 
The medical officers, who have been stationed at the barracks and hos- 
pitals or elsewhere, are, on mobilization of the army, assigned to the dif- 
ferent administrative and executive duties with the corps, divisions, and 
regiments, or to the division hospitals and ambulance companies, for the 
campaign. The hospital corps, which has been thoroughly instructed 
and drilled in the use of the litters and ambulances, in the handling of 
the wounded, and in the care and feeding and nursing of the sick, is now 

Vol. IL— 13 



194 MILITARY SURGERY AND THE CASE OF THE WOUNDED. 

organized into two separate and distinct detachments — one for duty with 
the field hospitals and the other to man the ambulances and litters for the 
collection and removal of the wounded from the field. 

United States Army. — The materials for a very comprehensive and 
efficient field service are at hand in the United States army, and the 
general plan of the work is outlined, but many of the practical details are- 
left to be arranged when the necessity shall arise. The regulations pro- 
vide that in time of war " the privates of the corps to perform the duties 
of litter-bearers, service with the ambulances, and at dressing and ambu- 
lance stations should number at least 2 per cent, of the aggregate strength 
of the command," and that " to every ten privates there should be an 
acting hospital steward, and to every thirty privates a hospital steward." 
As an auxiliary to this corps it is further provided that " there shall be 
in each company four privates designated for instruction as litter- 
bearers." They retain their status as combatants, being selected merely 
to " give first aid to the wounded or to carry them to the rear until 
relieved by the members of the hospital corps," after which they resume 
their arms and their places with the troops. The ambulance and hos- 
pital services of each corps are under the supervision of its medical 
director. The wounded are to receive attention — first, on the line of 
battle; second, at the first-dressing places; third, at the ambulance 
stations ; and fourth, at the division hospitals. The first-dressing places 
are to be established at the nearest point to the combatants where the 
wounded and those caring for them may not be unnecessarily exposed t0< 



/st Dioision. 
\lBri,g.\2Brig\3.Brii,\ 



♦ 



♦ 





Becpption 


^SnP 


^^71 



Fig. 252. 



Line of Boitte.— Regimental sur- 
geons—orderlies—dressing cases — 
company bearers— first-aid pack- 
ages-stretchers. 

First - Dressing places. — Ambu- 
lance surgeons — pack animals 
with light panniers— surgical tents 
—stewards, cooks and litter- 
bearers of the hospital corps. 

Ambulance Stations. — Surgeons — 
hospital corps men— ambulances — 
medicine wagons — tents — opera- 
ting table— light cooking appa- 
ratus. 

Division Field Hospitals in three 
sections— one for each brigade.— 
Hospital surgeons — stewards, 
cooks and nurses— army wagons. 



Snd Biuision.. 

, — A ^ 

\/Mrtjr. \S.Brig.\3.Brili.\ 



+ -I- 



♦ 






C 



Schematic diagram showing theoretical arrangement of the several lines of medical aid on the field, 

fire. Ambulance stations will be established at some place of security 
in rear or in some convenient building near the field. The division hos- 
pital will be located by the medical director after consultation with the 



FIELD OBOANIZATION. 195 

commanding general. Two-horse ambulance wagons, "equipped with 
such number of stretchers and other appliances as may be prescribed by 
the surgeon-general," are provided on the basis of three to each infantry 
regiment of five hundred men or more, two to each cavalry regiment of 
like strength, and one to each battery of artillery ; two such ambulances 
to the headquarters of each corps, and to each division train of ambu- 
lances two army wagons. Corps ambulance medicine wagons are contem- 
plated, but their number, contents, and distribution are left for future 
determination. The ambulance wagons of the corps are organized by 
authority of the medical director into trains for the different divisions 
and brigades, and a suitable number of officers of the line are to be 
detailed to take charge and handle them on the field as may be required 
by the medical officers in the collection and removal of the wounded. 
The privates of the hospital corps in the field in time of war will be 
organized into a company for each brigade, with their hospital stewards 
and acting hospital stewards, under the command of a medical officer. 
They camp near the division, brigade, or field hospital with the ambu- 
lance train, to be in readiness for service when needed. 

English Army. — As at present laid down in British regulations, an 
army corps numbering 37,431 of all ranks has with it 105 medical offi- 
cers all told, and 798 non-commissioned officers and men of the " medical 
staff corps." With a fighting strength of 35,000 men this gives 1 medi- 
cal officer to 333 combatants. There is one bearer company and one 
field hospital to each of the six brigades. 

A bearer eompany has 3 medical officers and 64 non-commissioned 
officers and privates of the medical staff corps, 1 officer and 36 enlisted 
men of the "army service corps," with 10 two-horse ambulances, 2 carts, 
and 2 wagons. 

The_^e^cZ hospitals have 100 beds each, with 4 medical officers and the 
usual personnel and transport. 

In action the bearer companies are formed into two sections, under 1 
medical officer, of 1 sergeant and 16 privates each ; 5 corporals and 3 
privates, in addition to the drivers, serve with the ambulances ; 1 sergeant 
is placed at each brigade " collecting station," and 2 medical officers, 4 
non-commissioned officers, 1 bugler, and 3 privates, including a cook 
and a tent for surgical operations, at each "dressing station." The 
ambulance wagons are likewise divided into two sections, one of which 
plies between the collecting and the dressing stations, and the other 
between the latter and the field hospitals. Each battalion of infantry 
and regiment of cavalry is provided with a medicine cart, which carries 
to the field the stretchers for the company bearers. A corporal orderly 
remains with each cart and the two panniers and circular surgical tent, 
while the private orderly takes from the cart his field companion and 
surgical haversack with the two water-bottles, and at the same time the 
company bearers fall out, place their kits on the cart, take the stretchers, 
and report to the battalion or regimental surgeon. 

European Armies. — The sanitary organizations of European armies 
are all constructed on the same principles and are very similar. A 
German army corps of twenty-four battalions of infantry 1000 strong 
has three " sanitary detachments " and two in reserve, with 1 captain and 
2 lieutenants of the line, 7 medical officers, 3 petty officers, 159 stretcher- 



196 MILITARY SURGERY AND THE CARE OF THE WOUNDED. 

bearers, 48 non-commissioned officers and privates of the "sanitary 
corps," and 31 " train-men " to each ; also 8 ambulance, 2 medicine, and 
2 baggage wagons, all two-horse, and 56 stretchers on the ambulance 
wagons. There are 12 field hospitals to a corps and 6 in reserve, of 200 
beds each, with 1 surgeon in chief, 1 staff surgeon and 3 assistants, and 
21 attendants. Two medical officers are supposed to be with each bat- 
talion of infantry and regiment of calvary, and one with each battery in 
the iield. The orderly knapsacks are brought to the front on the phar- 
macy wagons, and are carried on the field, with infantry and cavalry 
alike dismounted. In the Danish, Belgian, and Russians armies order- 
lies carry the medical knapsacks also on the march. 

In the Austro-Hungarian army each infantry division of 18,000 men 
has a " sanitary detachment " of 2 line officers and 95 men combatants 
organized to form two first-aid stations, one dressing station, one " am- 
bulance " and one " sanitary material reserve," also supplemented by a 
sanitary column of the German order of Knights. The " ambulance " 
has 3 surgeons permanently attached; the other dressing-places are 
supplied during battle by the regimental surgeons. Field hospitals are 
organized one for every division of infantry, but they are not attached 
to the divisions. They remain independent, to be assigned wherever re- 
quired. Every non-commissioned officer and soldier carries a small dress- 
ing package covered with sheet metal, containing 2 pieces sublimate gauze, 
2 pieces oiled silk, 10 grammes cotton, 2 safety-pins, and a triangular 
handkerchief or 4 metres of bandage. Each stretcher-bearer carries a 
leather pouch on his waist-belt containing 10 dressing packets, 1 tourni- 
quet, some cotton, a small cup, 2 triangular bandages, 5 safety-pins, and 
a pocket-knife; also 2 water-bottles. The "bandage-bearers" carry in 
action medical or surgical knapsacks brought to the field in the wagons, 
containing medicines, dressings, and surgical instruments. Each surgeon 
with the troops carries a leather pouch with two pockets containing some 
medicines and a small case of instruments. 

The details of sanitary organization in European armies are imports 
ant as examples for comparison and study, because they have in very 
recent years undergone thorough revision and improvement, the result 
of experience in war and to meet the new conditions presented by the 
introduction of modern firearms. Germany has been the leading power 
in these advancements, and other nations have closely watched and 
copied her methods, by which the various systems formerly in vogue 
have become more uniform in construction and more practically useful 
in operation. 

m. Pebparations for the Field. 

The principal things to be considered in preparing for the field in 
time of peace are the training of the hospital-corps men and the company 
bearers ; the selection and arranging of the most suitable instruments, 
medicines, and dressings in convenient form for use at the different 
points along the lines of medical aid ; the preparation of tents, bedding, 
cooking utensils, furniture, and appliances for the field hospitals ; and 
the organization of efficient means of transportation. All these import- 
ant matters have received close attention of late years from the medical 



PBEPABATIONS FOR THE FIELD. 



197 



departments of foreign armies, but, althongli great advancement toward 
perfection has been made, there is still room for improvement in many 
practical points. 

The hospital corps, especially the more intelligent members — stewards 
and acting hospital stewards — should receive, among other things, very 
careful and thorough instruction in the principles of antiseptic surgical 
methods, and they should be so trained as to make them reliable assist- 
ants in time of operations. In military surgical practice on the field, 
whether at the dressing stations or at the hospitals, it will rarely happen 
that more than one or two medical officers are available for each operating 
table, and they will have to depend upon the hospital-corps men for the 
most essential and important assistance in many trying emergencies. The 
members of this corps will not all be found to possess a like aptitude for 



Fig. 253. 



Fig. 254. 





Private, hospital corps, U. S. Army, field equip- Private, hospital corps, U. S. Army, field equip 
ment (front view). ment (rear view). 



such service, but each one, while being instructed in the general duties 
pertaining to all, should receive some special training in the performance 
of those functions for which he is by nature best adapted. Some will 



198 MILITARY SURGERY AND THE CARE OF THE WOUNDED. 



make better cooks than others, some better nurses ; some can assist at 
operations, and others may only be suitable for litter-bearers or ambu- 
lance-drivers. There is reason to believe that in the vast amount of 
labor and pains devoted to perfecting these men in the litter drill the 
great advantages to be derived from special training in other branches 
have been overlooked. Litter-carrying is not the only function, nor the 
most difficult one, which the hospital corps will be called upon to exercise 
in the field. It will be equally important to have a few men who possess 
some degree of skill in the preparation of diet for the sick, in the dressing 
of wounds and the nursing of patients in the wards, and in the handling 
of instruments and dressings in the operating-rooms. 

The company bearers perform their duties on the field under the orders 
of their own officers, and they should therefore be drilled and trained by 
their own officers. In order to ensure the presence at all times of four 
trained men to act as bearers and to be able to fill vacancies in case of 
accidents, the instructions should not be confined to any particular set of 
fours, but should be given alike to the entire company. The tactics as 
published for the bearer drill require no expert medical or surgical 
knowledge for their full comprehension, and the services of a medical 

Fig. 25.5. 




officer at these exercises are therefore not necessary. No instructions 
beyond those in bearer drill and in the various improvised means and 



PREPARATIONS FOR THE FIELD. 



199 



methods of transporting injured persons by hand will be required, as the 
eompany bearers have no concern with the dressing of wounds. Under 
present arrangements in modern armies stretchers intended for the use 
of company bearers are carried on the ambulance or medical wagons, 
which with large bodies of troops rarely reach the front in time to be of 
service during the early part of an engagement. Ordinarily, the company 
bearers will have to do most of their work as best they can without the 
aid of the regulation litter. Instruction, therefore, in other methods of 
carrying the wounded and in the construction of improvised appliances 
for this purpose will be of especial service to them, and it is, in fact, an 
essential part of their training. In the German army, in addition to the 
drill of the sanitary corps, a modified drill with elementary instructions 
in a few important methods of rendering first aid are given to all soldiers 
of a garrison. In the Swiss army the formation of fours as a unit for 
the handling of wounded on the field with the stretcher has been aban- 
doned as unsatisfactory and impracticable, and the method of two bearers 
acting together has been substituted in its stead. 

Material Required. — The important question as to what medical 
and surgical supplies will be most needed for the field must be deter- 
mined from past experience and present knowledge after a careful study 
of all available facts bearing upon the character and relative frequency 
of the diseases and injuries to be treated. The accompanying Table I., 

Table I. 



There were^ 


Officers. 


Men. 


Total. 


Per cent. 


Killed on the field 

Slightly wounded 

Severely wounded 


597 
1,881 
1,353 


7,138 
28,498 
21,701 


7,735 
30,379 
23,054 


12.6 
49.6 
37.7 


Total 


3,831 


57,337 


61,168 


99.9 


Eemained with the troops after 
being wounded 


688 


5,972 


6,660 


10.9 



extracted from Fischer's statistics of the killed and wounded in the 
Prussian army 1870-71, gives the gross results of 61,168 cases of shot 
injuries, from which it appears that in every 100 men hit, 12 were 
killed, 49 slightly and 37 severely wounded, and that 10 per cent, of 



Table II. 



Severely wounded. 

Head and face 

Throat 

Chest 

Back 

Abdomen 

Side 

Upper extremities 

Lower " 

Total 




Per cent. 

11.14 
2.23 
9.77 
3.44 
8.20 
4.28 
24.41 
36.52 

99.9 



the wounded remained with the command for treatment. The 23,054 



200 MILITARY SURGERY AND THE CARE OF THE WOUNDED. 



severe wounds were distributed over different parts of the body, as shown 
in Table II. Turning to the records of the War of the Rebellion, irb 



Table III. 



245,790 shot wounds, War of the Eebellion. 

Penetrating wounds of the chest . . 

" " " abdomen . . 

Primary lesions to blood-vessels . ... 

" hemorrhage 

Fractures of hip-joint 

" of Jong bones, thigh ... 

" of the knee-joint . .... 

" of long bones of the leg 

" of ankle-joint 

" of shoulder-joint 

" of long bones, arm 

" of elbow-joint ■ 

" of long bones, forearm 

" of wrist-joint 



Number. 


Per cent. 


8269 


3.36 


3717 


1..51 


48.5 


0.19 


110 


0.04 


386 


0.16 


6738 


2.74 


3398 


1.38 


9171 


3.79 


1722 


0.70 


1579 


0.64 


8245 


3.31 


2816 


1.15 


5194 


2.11 


1509 


0.61 



245,790 shot wounds the special injuries shown in Table III. were noted. 
These statistics are based on a large number of cases, and are therefore 
reliable. 

Allowing for some difference in results to be obtained under the new 
conditions with the new armament, it is thus shown what percentage of 
men will be killed in battle, what proportion will be slightly or severely 
wounded, and the exact seat and character of all the graver injuries. 
Add to this about 1 per cent, for the usual accidents and from 3 to 5 
per cent, for sickness, and there is all the information necessary under 
ordinary circumstances to guide in the selection of medicines, instru- 
ments, dressings, or other material and transportation to be taken to the 
field. The necessity for some means of immobilizing broken bones will 
be at once apparent. From two to three compound fractures of the 
tliigh, three to four of the leg, three to four of the arm, two to three of 
the forearm, and one or more each of the knee- and elbow-joint may be 
expected among every hundred of the wounded. 

Splints of light wire, which may be carried in the roll or in pieces 
of suitable size, are very convenient, especially for first dressings. The 
French surgeons speak favoi'ably of this material. The coil given to it 
in the roll imparts additional strength in the longitudinal direction. 
Plaster splints are of great service in the field, but formal dressings of 
this kind consume time and require some skill and assistance in their 
application, and there is the additional disadvantage that they are dif- 
ficult to utilize in damp or rainy weather. Instead of using the heavy 
plaster dressing alone, it is better to combine it with some other lighter 
material as a basis. Wire splints may be cut from the roll, and after 
being adjusted with proper padding beneath they may be secured by a 
couple of plaster rollers, or some other light splint material, or even ex- 
temporized splints out of reeds, brush, or twigs may be used in the same 
way. Thin wooden splints are very practical and easily carried. A number 
of these may be brought along in the mule panniers, and when applied 
under plaster rollers they make very firm support. Like the combina- 
tion of wire and plaster, they are lighter and quicker to dry, and more 



PREPARATIONS FOR THE FIELD. 



201 



readily applied and much more easily removed, than the ordinary plas- 
ter splints for temporarily iixing broken limbs. Telegraph wire with the 
aid of a file or a file-backed knife has also been used for this purpose. 

Extemporized splints are not to be relied upon too much in the field, 
for although there may be occasions and places where the materials for 
their preparation are at hand, this will often be found difficult or 
impracticable on account of the time and inconvenience involved in 
procuring them. When on an active campaign the troops happen to 
be in the vicinity of swamps or thickets where reeds, rushes, tall sedges, 
or the thin, straight shoots of such shrubs as the red osier dogwood or 
the euonymus or willow abound, the opportunity may be improved by 
having a few splints prepared to supplement the limited supply on 
hand. Guns, ramrods, and bayonets constitute the least desirable 
material for this purpose, and they are not always available, although 
a rifle may sometimes be utilized as the long splint on one side of a 
fractured lower extremity. 

The application of splints requires a considerable quantity of other 
material for padding and bandaging, principally jute, cotton, gauze, and 
adhesive plaster. The latter may often be used on the outside to secure 
dressings in place with economy of time and material. All these articles 
should be in readiness for use in convenient parcels compressed into as 
small a bulk as possible — bandages cut and rolled, adhesive plaster on 
spools, and cotton and gauze in small cartoons. Expense cannot be 
considered in the preparations for war until after all other requirements 
have been satisfied. 

Antiseptic and Aseptic Materials. — Medicines, instruments, and dress- 
ings must be selected to conform to the latest advancement in medical 

Fig. 256. 




U. S. army regulation panniers, 1894. 

and surgical practice. The demands of antiseptic principles are to be 
met in military surgery on the field as far as possible, limited only by 
the necessities and exigencies of warfare. The antiseptic agent most 



202 MILITARY SURGERY AND THE CARE OF THE WOUNDED. 

extensively employed in the present status of surgical technique is heat. 
Fire and a limited amount of water can usually be secured on the field, 
and they can always be supplemented by such chemical antiseptics as 
the bichloride of mercury, carbolic acid, kresol, and others. Tablets 
composed of about 7.5 grains each of corrosive sublimate and the 
chloride of sodium or ammonium are very convenient for field use. One 
tablet to a pint of water makes a 1 : 1000 solution. Pure carbolic acid 
in crystals may be carried in small strong bottles, and, for convenience 
of measuring, it may be reduced to a liquid by the addition of a few 
drops of water when wanted. Trikresol, v/hich appears to be a very 
valuable surgical antiseptic, or formalin occupies very little space. 

Fig. 257. 




Serin's emergency pocket operating-ease. 

Catgut ligature for the field should be wound on small glass spools, 
and, after being sterilized by boiling in absolute alcohol, may be kept 
m bottles of absolute alcohol secured by rubber stoppers and caps. 
When the ligature is to be used, the cap and stopper are removed and 
one of the spools lifted out with forceps and placed in the operator's 
hand or in alcohol, or the thread may be drawn up from the bottle and 
cut as required, but it is never to be drawn through a hole in the stop- 
per. The smallest bottle of catgut ligature for convenience at the front 
might be about an inch square by an inch and a half high, which will 
contain 3 yards of fine, 21 yards of medium, and 1 yard of coarse 
ligature on three glass spools. Silkworm gut mav be carried dry, and 
sterilized by boiling with the instruments or otherwise, or by immersion 
in a 1 : 1000 bichloride solution as wanted. Silk ligature is best carried 
in the needle threaded and sewed into pieces of linen or cotton stuff in 
lots of from one to three or four dozen. These may be sterilized by 
boiling for a few minutes with the instruments. Bichloride gauze may 
be carried in small sealed packages with safety, but carbolated and 



DISTRIBUTION OF MATERIAL ALONG THE LINES. 



203 



salicylated dressings are not reliable except when freshly prepared, nor 
are they in the least necessary in the field. 



IV. Distribution of Material along the Lines op Medical 

Aid. 

On the Line of Battle. — It is obvious that medical and surgical 
materials and appliances for field service must be especially selected and 
adapted to meet the needs of each particular point along the lines of 
medical aid for which they are designed. The dressing-case or pouch 
carried by the regimental surgeon's orderly is for use with troops away 
from all other sources of supply, and it should be equipped and kept 

Fig. 258. 




Medical pannier mounted. 



for that purpose only. Sick and wounded men will be left behind 
when the troops advance, and there will be no demands upon its con- 
tents except for the treatment of such acute cases of illness or injury 



204 MILITARY SURGEBY AND THE CARE OF THE WOUNDED. 



as may happen on the march or in action. As the surgeon is obliged 
to remain with his regiment, he will have few opportunities for the 
performance of operations or to attend to sick or wounded men unable 
to keep up with the command. These conditions indicate at once what 
articles are to be supplied to the regimental surgeon and his mounted 
orderly. A few simple medicines for the relief of pain, shock, fainting, 
nausea, diarrhoea, heat, exhaustion, and the like ; a pocket case of instru- 
ments for small operations ; antiseptic tablets, carbolic acid, cocaine, 
chloroform, and bottle for ansesthesia ; catgut, silk, and silkworm-gut 
ligature ; wire or wooden veneer splints ; plaster rollers wrapped and 
sealed separately in paper ; compressed gauze, jute, gauze bandages, a 
spool of adhesive plaster, and a 2^-inch rubber bandage. By properly 

Fig. 259. 




Surgical pannier dismounted. 

regulating the proportionate amount of these articles, and with the 
frequent opportunities to renew what has been used, all of them can 
be carried and made available. 

At the first-dressing places the articles needed include all those above 
named, but in much larger quantity, and with the addition of a case 
or two of well-selected and compactly arranged instruments for general 
operations, including the elevation of depressed fracture of the skull, 
tracheotomy, amputations, and the ligature of arteries; an operating 



DISTRIBUTION OF MATERIAL ALONG THE LINES. 



205 



tent, a cook, and some sort of small portable cooking apparatus and con- 
densed liquid nourishment. In many European armies the little first- 
dressing packages carried by the soldiers constitute the only aid pro- 
vided for sick or wounded at the front until the medicine carts come up 
and bring the orderlies with their knapsacks, haversacks, and water- 
bottles and the stretchers for the company bearers. In our service the 
surgeon's orderlies are mounted and carry the pouches with them on 
the march, but there is nothing provided for the first-dressing places 
until the arrival of the panniers, which are carried on the ambulances ; 
and this may not, and usually does not, occur until long after the 
engagement is in progress and the field is strewed with the wounded, 
wheeled transportation cannot be depended upon to reach the scene 
of conflict until some hours after a considerable number of men have 
been injured and in need of assistance. To meet this necessity the 
French have, instead of the battalion medicine carts, paek-mules carry- 
ing panniers which keep well closed up with the troops. This arrange- 
ment is greatly needed in our army, not, however, to take the place of 
the brigade medicine wagons which serve as a base of supplies for 
distribution to other points, but in addition and auxiliary to them. 
At least one pack-mule with two light panniers should be provided 
to each brigade to supply material for the first-dressing places in the 
interval between the commencement of hostilities and the arrival of 

Fig. 260. 




Panniers as an operating table. 



the hospital-corps men with the ambulance train. The surgical tent 
and at least two or three even of our present heavy stretchers 
might also be brought up on the mule. A light form of stretcher, 
with perhaps bamboo poles or one that folds and has a joint of sep- 
aration transversely, is much needed for this particular purpose. 
The panniers serve for an operating table. The cook may be mounted 
and utilized to bring up the mule. Scarcity of water is often a serious 
difficulty at these places, but the surgeons may sometimes be able to 
locate them on the borders of a stream or near a well or spring. 



206 MILITARY 8URQEBY AND THE CARE OF THE WOUNDED. 

Ambulance Stations. — The equipment of an ambulance station 
comprises some tents, which when practicable are pitched in connection 
with such local buildings or shelter as may be found available ; a light 
field cook-stove and commissary stores ; stimulants ; concentrated food 
for the preparation of hot coftee, soup, and other nourishment; and 
the brigade medicine wagons supplied with instruments and appli- 
ances necessary for permanent or emergency dressings, and for such 
operations as circumstances require or as time and opportunity may 
permit. These stations should be so organized as to supply their own 
transportation in the ambulances entirely independent of the army 
wagons, in order that they may get to the field and into operation as 
early as possible after the trouble begins, and without waiting for the 
heavily-laden trains, which must necessarily be delayed. The value of 
medical aid on the field is often dependent upon the promptness with 
which it is rendered. The fate of many cases is determined by the 
earlier or later arrival of these light, quick-moving vehicles with needful 
assistance. Ambulance stations, like the division hospitals, are always 
to be located where there is a good supply of water, fuel, and, when 
practicable, hay or straw. There should be at least three medical officers 
and a sufficient number of hospital-corps men. The wounded are often 
obliged to remain at the ambulance stations during the first night and 
sometimes longer after a battle, and in case of victory the field hospitals 
may be located there, or when defeat is sustained the disabled may be 
collected and left there with a medical officer under the supposed protec- 
tion of the Geneva articles of agreement. 

Field Hospitals. — In our army a field hospital is organized to meet 
the requirements of each division, but it may be separated into its integral 
parts and distributed to the brigades or regiments when they are operating 
as independent commands. It is transported on army wagons. The 
tents, furniture, and most of the appliances appear by comparison to 
possess qualities which in point of practical utility are fully up to if not 
ahead of those of any foreign power. The light folding cots, chairs, 
and tables are especially noted for excellence and suitability to their 
purpose. The most desirable location for a field hospital during hot or 
even moderately cool weather is in the vicinity of large barns with 
adjoining sheds, which can be thrown open so as to furnish shelter over- 
head and a free circulation of air throughout. Aroimd this the tents may 
be pitched, and with the sides raised conditions are obtained which admit 
practically of an out-door treatment for the wounded, under which, not- 
withstanding many apparent discomforts, they do far better than in close 
quarters. 

It is a matter of the utmost importance that the field hospitals, when 
they are to be established at all, should be got into operation in time to 
receive the wounded soon after they are injured, and before many have 
perished or suffered serious impairment of the chances of recovery for 
want of aid which can only be supplied at some permanent place of 
rest. The Surgical History of the War of the Rebellion records many 
cases of gunshot fractures and other injuries to soldiers who received the 
first serious attention only after journeying over long distances, during 
several days, from the field, sometimes to the general hospitals. For- 
warded from place to place for one reason or another, and jolted 



TRANSPORTATION. 207 

about until their wounds began to suppurate, the treatment which came 
at last was often too late to save them, and was only followed by the 
addition of another specimen to the Army Medical Museum, where the 
ghastly evidence of numerous instances of this kind may be found. 
It is rarely possible to hurry up the heavy wagons, but the medical 
staff detailed for hospital duty should come on the field with the troops, 
and as soon as the engagement becomes settled, or even earlier, they can 
usually select a site for the field hospital, and with a little assistance 
begin work at a place where the wounded may be sent, and where they 
may remain at rest for some time after operations and dressings. In 
order to carry this plan into effect, it will only be necessary to organize 
an advance or flying detachment of the field hospital, consisting of a 
medicine wagon and one or two light ambulance transport wagons carry- 
ing about three tents and three operating tables, with such instruments, 
dressings, and appliances as will enable the three operating surgeons, 
their assistants, and a few non-commissioned officers and nurses to begin 
and carry on their labors while the heavier wagons and material of the 
train are coming up. 

V. Tbanspobtation. 

The enormous trains of ammunition, provision, and baggage wagons, 
artillery^ ambulances, horses, and mules, that accumulate in the rear of 
an army form encumbrances to its movements which should be under- 
stood and appreciated by those who are preparing supplies to take the 
field. In 1862, when McClellan's army of about 100,000 men moved 
back from the Chickahominy to the James River, there were 4000 
wagons, 500 ambulances, 350 field-pieces, 60 siege-guns, 40,000 horses 
and mules, and 2500 head of beef-cattle in its train, " following a single 
road, a mere woodland path, constantly occupied by troops on the march 
or obstructed by infantry or cavalry, amid the din of battle, which was 
heard simultaneously in front and rear and on the flanks." ' The one 
object of solicitude was this train, which was kept together in front and 
closely guarded. No part of it was available for the benefit of sick or 
wounded except a few light flying ambulances, and many of the more 
severely injured in all the battles had to be left on the field. The longer 
the marches undertaken, the farther from railroads and bases of supply, 
the greater the train of an army becomes and the more difficult it is to 
handle and protect. The narrow country roads winding through forest 
and thicket and over streams and hills are beset with ruts and bog-holes 
which increase in depth with every vehicle that passes. On a dry, 
sultry day men and animals are enveloped in clouds of dust ; when it 
rains the streams are swollen until every little ditch becomes a formid- 
able obstruction. "Wheels sink into the soft ground, wagons break down 
9r stick fast in the mud, their contents are distributed to others already 
Overloaded, mules give out, roads become blocked, trains are delayed, and 
freight often has to be abandoned or destroyed. The ambulances are 
crowded, especially if the weather be inclement or there has been much 
fighting, and numerous sick and wounded straggle along by the wayside. 
Jrhejo6ing-of .wagons, the braying of mules, the sharp cracking of whips, 
' Civil War in America, Compte de Paris. 



208 MILITARY SVBGERY AND THE CABE OF THE WOUNDED. 

Fig. 261. 




SCALE. 



e FEET. 




Eegulation two-horse ambulance, pattern of 1892. 



TRANSPORTA TION. 



209 



the wild shouts of the di-ivers characterize the scene, while the sound of 
distant cannon gives warning that a battle may be near at hand or in 
progress. The troops farthest to the front are the iirst to be engaged, 



Fig. 262. 




Litter open. 
Fig. 263. 




Litter partially closed. 
Fig. 264. 



Side view. 
U. S. army regulation Iianl-litter, 1894. (New pattern under eonsideration.) 

but in the mean time the long train, " winding; its way likq a huge serpent " 
over the road, carries with it almost everything provided for the sick and 
wounded, and may not reach the field until late in the night or not at all. 




The Indian travois as improvised in the field. 



The more severe the contest in front and tlie more doubtful it becomes, 
the more closely the train is kept together and guarded, and consequently 
the less available its material is at the very time when it is most wanted. 

Vol. II.— 14 



210 MILITARY SUBGERY AND THE CARE OF THE WOUNDED. 

At the battle of Chancellorsville, Va., May, 1863, the trains, including 
the ambulances and medicine-wagons, were parked six miles from the 
field on the opposite bank of the Rappahannock. Later on, authority 
was given to take a very few ambulances only to the front. Medical 
supplies brought up in panniers on pack-mules constituted the chief 

Fig 266 



a^Bei^a"l!!.'"i!iii-j - 



;„,„|i„ |^i.,^,ujy^ 



- ^ '] "Mallf 



mp,f^^mgmm^W^fmm 



"■^■■4.t'l"| i«a-^-i=t'«.lal' -i»M.A- 



n;jL»Jk 



Dr. N. Senn's bamboo-rod stretcher. 

resources of the medical department from May 1st to the 5th, when the 
troops recrossed the river. 

At Gettysburg, on July 1st, the commanding general ordered that all 
trains except ammunition and ambulance wagons be sent back and parked 
several miles away. On the 2d, while the battle was in progress, the 

Fig. 267. 



::;::::ft..^.v 






_-,JMg,|,i : , -, ,,i,.-| an>UML-|iHaPiiiaBiii!aiiii«iilBiahMJPj^ 



Dr. N. Senn's stretcher folded for transportation. 

trains, including the hospital wagons and the especial train of medical 
supplies, were sent still farther back to a point about twenty-five miles 
from the field. In most of the corps the medicine-wagons were taken 
to the front with the ambulances, and thus some supplies were available 
for immediate use. Medical Director Letterman in his recollections of 



Fig. 268. 




Dr. N. Senn's field operating-table. 



the Army of the Potomac says : " The want of tents, cooking apparatus, 
etc. occasioned by the recent orders was to me, in common with all the 
medical officers, a cause of the deepest regret and to the wounded of 



THE ARMY MEDICAL OFFICER AND HIS WORK. 



211 



much unnecessary suffering. Without proper means the medical depart- 
ment can no more take care of the wounded than the army can fight 
without ammunition. The medical department had these means, but 
military necessity deprived it of a portion of them, and would not per- 
mit the remainder to come upon the field. As soon as the battle termi- 
nated I requested the commanding general to allow me to order to the 
hospitals the wagons conta-ining the tents, etc. and the extra supplies. 
After much persuasion he gave me authority to order half the number 
of wagons. I at once gave directions to send for them, and also for the 
remainder as soon as I could obtain permission to do so. These were 

Fig. 269. 




Dr. N. Senn's field operating-table when folded. 



of much service when they arrived, but they could not reach the field in 
time to protect the wounded from the drenching rain which fell after the 
battle." The exposure of the whole field occupied by our troops to the 
fire of the enemy made it impossible to place the hospitals in rear of 
their divisions. Most of them were entirely out of the enclosure formed 



Fig. 270. 



Dr. N. Senn's field operating-table with top or stretcher, the latter wrapped around the folded table. 

by the horseshoe-shaped line of battle. Even the temporary halting- 
places in the rear of the column were so unsafe that they had to be 
abandoned. Houses and barns, but chiefly the woods, were used as 
hospitals. 

Transport for the sick and wounded generally is ample, and supplies 
are furnished in abundance, but in time of battle they are seldom to be 
had when most wanted. In order to get assistance to the wounded with 
more punctuality and more certainty, as well as more promptly, in 
future, less dependence must be placed upon the heavy wagons, and some 
material mu.st be brought to the front on pack-mules and in advance 
detachments of the field hospitals. 



VI. The Army Medical Officer and his Work. 

The medical department of modern armies now stands about on a 
footing with the other staff departments. The independence of the 
medical corps and the supremacy of its authority in all matters affecting 
the health of the troops have been at length practically conceded. This 
concession has come about gradually as the competency of the medical 
officers improved and the value of their services was more and more 
appreciated. When they, as a class, were of little or no account, they 
received little or no consideration. That they now occupy a high posi- 



212 MILITARY SURGERY AND THE CARE OF THE WOUNDED. 

tion in the estimation and confidence of the military authorities is the 
direct result of their success in organizing and extending the usefulness 
of the military medical service. The honors conferred upon them are 
due alike to their own scientific attainments and to the immense improve- 
ment in the health, morale, and efficiency which has been wrought among 
the troops of all nations through their efforts. 

In Camp and on the March. — The surgeon is the sanitary officer of 
his command. Under modern army administration his advice is sought 
and given in all matters that relate to the physical or mental character 
of the men, to the location of camps and garrisons, the construction of 
buildings, ventilation, heating and lighting, quality of food and clothing, 
cleanliness, and general police and sanitation. The army medical officers 
have entire charge of the care, feeding, nursing, treatment, and transpor- 
tation of the sick and wounded. It is their task not only to provide for 
the wounded on the battle-field, where hundreds and sometimes thousands 
of men are shot down within a few minutes, but to meet and keep back 
the enemy in the rear — to protect the troops against attacks of scurvy, 
diarrhoea, dysentery, and malaria, the invasion of cholera, yellow fever, 
and typhus, and to ward ofP numerous other more or less serious troubles 
which carry on a perpetual skirmishing about every military camp. 

In times of peace, in the quietude of garrison life, with comfortable 
quarters, good food, regular exercise, strict discipline, and proper sanitary 
surroundings, it is no more difficult to maintain a state of health among 
soldiers than among citizens of the same locality. The constant care and 
training to which they are subjected under the supervision of experienced 
officers; the habits of cleanliness, obedience to orders, and methodical 
rules ; the inspiration of military pride, martial music, and warlike dis- 
play ; wholesome recreation and congenial companionship, — all have an 
elevating influence on the manhood of a soldier and tend to promote his 
moral and physical health. But in the field and in camp the conditions 
are different. Sudden changes in the mode of living, in the kind and 
quality of food, means of cooking, irregular meals, exposure to the Aveather, 
nervous excitement, loss of sleep, defeat and depressing influences, invite 
and are soon followed by disease in some form, especially among the un- 
seasoned recruits. Macleod says : " It is not the numbers who fall in 
action that constitute the greatest loss ; they are but a small proportion 
to those who in the course of every campaign sink under neglected 
wounds, want, fatigue, and disease." 

The rapid progress made during recent years in sanitary science and 
preventive medicine has caused the true value and importance of army 
hygiene to be appreciated by all classes of military men. Through the 
advancements in pathology and bacteriology some of the diseases and 
injuries which most interest the army surgeon are now better understood, 
and therefore better methods of prevention and treatment have become 
available. Medical officers everywhere have been prompt to take ad- 
vantage of this knowledge, and to make practical application of it for the 
benefit of troops in the field. The favorable results of these measures are 
shown in the medical and surgical records of recent wars, and of our own 
campaigns on the frontier, as compared with those of former times. 

Sick and wounded, unable to keep up with their commands on the 
march, are carried on the ambulance train, and those injured or taken ill 



THE ARMY MEDICAL OFFICER AND HIS WORK. 213 

during the day are allowed to fall back to it, where at least one medical 
officer to each brigade is present to receive them and to render such aid 
as may be practicable until the camping-place is reached, when they are 
usually quartered Avith their companies, but, when necessary, the regi- 
mental or a part of the brigade or division hospital may be temporarily 
organized for their benefit. There is usually a morning sick-call, at 
which the cases requiring ambulance assistance are selected and designated 
for the march. But the experienced surgeon will soon find that it is 
much wiser to simply make an informal inspection of such cases as may 
be presented, extending his aid to the modest and the ambitious, instead 
of offering a general invitation to men to give up for slight ailments and 
overcrowd the ambulance train early in the day. One of the most dif- 
ficult and disagreeable duties of the regimental surgeon is to ride in the 
rear of the command on a long fatiguing march and keep up the strag- 
glers, deciding promptly and resolutely who can continue his exertions 
and who must be allowed to fall out. 

On the Battle-field. — Surgery learned in the colleges and witnessed at 
the hospitals and in the well-appointed and thoroughly equipped ope- 
rating-rooms, though the same in principle, is quite different in practice 
from that which is presented at the theatre of war. The conditions and 
circumstances under which the military surgeons have to perform their 
work, the peculiar class of injuries to be treated, and the necessarily 
limited resources available for the purpose are its distinguishing features. 
The ligation of an artery or the amputation of a limb may be a simple 
matter where there is ample time and plenty of competent assistants, and 
where all the necessary means and appliances are at hand to add to the 
convenience and success of the operation ; but when this has to be done 
on the field with hastily-prepared and deficient arrangements, with inad- 
equate help or none, in the midst of confusion and hurry, and the clamor 
of wounded men suffering on all sides from want of attention — in the 
night, most likely, with only the flickering light of a candle or two for 
illumination — in the rain and mud, with cold hands and benumbed fingers, 
tired and exhausted from overwork, it is quite another thing. 

On the night after a battle the surgeons find no time for rest. They 
must take advantage of the opportunities offered by darkness and the 
cessation of hostilities to gather in the wounded and attend to them. 
These are often widely scattered, and must be sought after in woods, 
thickets, and fields, and collected together under many difficulties. For 
two or three consecutive days and nights the demands upon the strength 
and endurance of the surgeons from these exhausting labors may be 
almost continuous. The sultry heat and dust of the day are not unfre- 
quently followed by a drenching rain with its unpleasant accompaniments 
of wet clothes and deep mud. The wounded will be found lying in 
ravines and on rocky hillsides where the access of ambulance wagons 
is difficult, or they may be out on the open plain exposed to the enemy's 
fire, where the least appearance of a light is sufficient to attract a shower 
of bullets. 

On the first line of assistance one medical officer for_ each regiment 
remains with his command during the action to give aid and comfort 
to the wounded and to superintend their collection and removal by the 
company bearers. Lines of battle sway back and forth or swing round, 



214 MILITARY SURGERY AND THE CARE OF THE WOUNDED. 

and men may fall and lie for hours or days between the two contending 
forces. Skirmishers and reconnoitering parties advance from time to 
time in different directions, and thus the injured become separated and 
sometimes difficult to reach. They must be found and supplied with 
water and such remedies as may be suitable for the relief of pain, shock, 
syncope, etc., provided with a diagnosis card, and sent or carried to the 
rear. The application of dressings is not often practicable under such 
circumstances. It is of far more importance to hasten the removal of 
the wounded to a place of greater safety. While one wound is being 
dressed another may be made. 

The identity of the bodies of men killed on the field is often lost. 
The evidence of this is to be seen in the long rows of tombstones 
marked " Unknown " in our national cemeteries. To avoid in future 
the many distressing consequences that arise from this circumstance, 
every soldier going into battle should be provided with a small metallic 
tag, and required to wear it about his neck next the skin, bearing his 
name, company, and regiment and the date and place of his birth. 

At the collecting or first-dressing places the dangers are less and the 
conditions more favorable for offering the wounded some attention. 
There they are to be divided into three classes and designated accord- 
ingly : First, those who are able to walk to the ambulance stations or 
to the field hospitals ; second, those who require transportation ; and 
third, those whose condition or injuries are such that they must remain 
temporarily where they are. The surgery to be done at the first-dress- 
ing places will depend very largely on circumstances. If the hospitals 
are already established or nearly so, and the ambulance train is in 
position, then nothing more should be undertaken than just what is 
necessary to prepare the wounded for their journey to the ambulance 
station or to the hospital. Attention to the wounds in that case should 
be limited to such measures as will suffice merely to protect them against 
infection through the medium of dust, dirt, soiled clothing, or handling, 
to immobilize broken bones, and to arrest hemorrhage, until the patients 
can be brought to a place where better preparations have been made 
for taking care of them. 

The fresh surface of wounds should be guarded against the touch 
of septic instruments or fingers on the battle-field as strenuously as they 
are on the operating-tables of the best-appointed hospitals. Although 
it appear that loose fragments of bone are present which may have to 
be removed from a wound, it is better to let them remain temporarily, 
lest by disturbing the parts some further extensive interference might 
become necessary for which the surgeon is not then prepared. They 
can do no serious harm until the wound comes to be examined under 
proper antiseptic precautions. Even foreign bodies, such as fragments 
of clothing, missiles, etc., should not be sought after beyond the surface 
of the wound for the same reasons. 

With a few bichloride tablets, a piece of soap, and some appliance 
for boiling water the field surgeon can sterilize instruments, clean his 
hands and the region of wounds, apply dressings, and do minor opera- 
tions, such as occupy but little time and require but very limited means 
and assistance. During heavy engagements the wounded often accumu- 
late at the first-dressing places so rapidly that neither time nor material 



THE ARMY MEDICAL OFFICER AND HIS WORK. 215 

can be had for elaborate dressings, but as many as practicable of the 
slighter injuries may be permanently dressed to relieve the labors of 
those at the ambulance stations and hospitals. In exposing a wound 
it should be remembered that clothing in the field is very limited, and 
sometimes very difficult to replace when destroyed. Have the thought- 
fulness and consideration to open it along the seams \vlien practicable, 
so that it may be laid back over the limb or body again when the wound 
is dressed. The surrounding parts can be quickly scrubbed with soap 
and water and a 1 : 1000 solution of the bichloride poured over them, 
washing away at the same time any particles of sand or dirt that may 
be on the wounded surface, but the protecting clot, if any happen to be 
present, should not be disturbed. 

Some military surgeons then prefer to dust the wounds with iodoform 
and apply a dressing of dry gauze. The aseptic character of dry dressings 
is not so reliable in the field as in hospital, where they come direct from 
the sterilizer. It would be better, perhaps, not to depend too much 
upon so-called aseptic and antiseptic dressings for field use, but rather 
make arrangements to boil or otherwise sterilize them on the spot. It 
will usually be practicable at the first-dressing places to have hot water, 
to which a few corrosive-sublimate tablets or 1 per cent, of soda may 
be added if desirable, and to immerse the gauze in this and wring it 
out. The difficulties and inconveniences of carrying and handling 
sterile gauze — except in small quantity in sealed tin jars for some special 
purpose — would thus be avoided. The objections raised by many 
European surgeons to the first-dressing packages carried by soldiers and 
attendants might thus be overcome, and the materials contained in them 
utilized to advantage and with safety. 

Dr. Jos. Bogdanik of Biala says on this jjoint : " I would rather 
wounds were brought to me for treatment which had been exposed for 
hours to the influences of air and svmshine than those to which, with 
unclean hands, the sweat-covered materials of these dressing packages 
had been applied." It will not do to condemn these packages, for with 
proper precautions they may be turned to good account. Esmarch 
mentions a number of instances where in the German service they 
furnished the only material available for dressing wounds during and 
for some time after battles. 

Dressings can only be applied by the surgeons themselves, or by the 
few hospital corps men who have been trained to assist at operations, and 
who are reliable and competent to take proper antiseptic precautions. 
The importance of having a number of hospital-corps men thoroughly 
trained to assist in this work under the supervision of the surgeons 
will be apparent. It is said that the fate of a wounded soldier often 
depends upon the first person who attends to his wounds. The unclean 
touch of attendants or of so-called surgeons who venture to handle a 
wound without being thoroughly prepared to do so is more dangerous 
than the original injury. Dirty fingers and probes in past wars have 
probably caused more deaths, more cripples, and more agony than the 
rifle bullet. Ignorance then was a sufficient excuse, but this can never 
again be pleaded in bar of trial. The one great thing which the 
new surgery has made possible on the battle-field is the prevention 
of wound-infection. Every unauthorized person — including the soldier 



216 MILITARY SURGERY AND THE CARE OF THE WOUNDED. 

himself and the company bearers — should be strictly prohibited from 
touching the wounds under any pretext whatever, and surgeons or 
their authorized assistants who are found guilty of doing so without 
proper antiseptic precautions should be promptly punished. 

Hemorrhage is often claimed as an excuse for handling wounds. 
Erroneous ideas seem to prevail in the popular mind as to the danger 
of liemorrhage after gunshot wounds, and some misleading accounts and 
^■ery unsurgical recommendations have been given about it even in 
quite recent literature. The popular apprehension may have arisen 
from confounding that which is immediately and necessarily fatal on 
the field and that which comes on secondarily with primary hemorrhage 
proper among the wounded. Gunshot hemorrhage either does its fatal 
work at once and under circumstances where surgical aid is impractica- 
ble — often in wounds of the head, chest, or abdomen — or it is so slight 
as to be, usually, of little consequence until the time when secondary 
or delayed primary hemorrhage may sometimes be apprehended and the 
patient has already reached the hospital. 

Parties interested in the manufacture of tourniquets might be ex- 
pected to work upon the popular fears for the sale of their patented 
wares, but it is unfortunate that any respectable medical authority 
should countenance the general issue of them in opposition to the 
experience of so many eminent American and foreign military sur- 
geons, who have expressed their belief that primary hemorrhage among 
the wounded on the battle-field, requiring the application of a tourniquet, 
is a very rare occurrence. Of 245,790 shot wounds during the War of 
Rebellion, 110 cases of primary hemorrhage are recorded, probably less 
than half of which were in the extremities, where a tourniquet could 
have been applied. Notwithstanding these facts, it has been recom- 
mended that every soldier shall provide himself with a stout piece of rub- 
ber tubing or a pair of rubber suspenders, which in case of wound in the 
extremities with any hemorrhage are to be wound around the limb and 
drawn up tight by the aid of a comrade. If the bleeding stUl continues 
(as it often will, for the constriction may be on the wrong side of the 
wound), one or both openings are to be plugged by thrusting a handker- 
chief or some such material into them with the finger. In this condition 
the unfortunate man passes into the hands of others, who will not dare 
to interfere lest the hemorrhage (which probably never was of the slight- 
est consequence) should be renewed, until finally, after several hours, he 
reaches the hospital with the limb strangulated, the main vessels con- 
tused, the principal nerve-trunk paralyzed and permanently injured, and 
the wound infected. It is better that one man should perish quietly 
and painlessly on the battle-field from hemorrhage than that several 
men should suffer a lingering death from infected wounds in the 
hospitals. 

When, in case of serious hemorrhage, the surgeon is not prepared to 
tie the vessels at both ends in the wound, the limb may be elevated and 
a bandage applied from the toes or fingers upward with an aseptic com- 
press on each opening and one over the line of the main artery. Every 
surgeon should have at hand a good two-inch rubber bandage for use in 
case of operation, and when a tourniquet becomes necessary this bandage 
may be used, supplemented by the application of a roller bandage to the 



THE ARMY MEDICAL OFFICER AND HIS WORK. 217 

whole limb and an aseptic compress over the wound. The portion of 
the rubber roller not unwound is tucked under the last turn to make 
pressure over the main arterial trunk, and urgent attention called to the 
case on the diagnosis card. When serious internal hemorrhage is going 
on, a quantity of blood may be saved by constricting one or more of the 
extremities \vith the rubber bandage pending operatiAC assistance, but 
this, like all other applications of the tourniquet, can only be properly 
done by expert hands. 

At the ambulance stations the surgeons are equipped to do formal 
operations and dressings. As much of this work as practicable is done 
there to relieve pressure at the hospitals, and as many as possible of the 
slighter injuries are permanently dressed. The wounded are received, 
and after careful inspection some are sent to the operating-room, some 
to have their wounds dressed, and others are held to await the establish- 
ment of the hospitals. In European armies the severely and the slightly 
wounded are separated at this point and sent to different sections of the 
field hospitals. Hundreds of men with slight injuries may be treated 
and returned to their commands without leaving the field, whereas if they 
once get away it is difficult to get them back again. 

Among the most important questions likely to arise will be what 
course to pursue in certain cases of compound fractures. Now that the 
means of avoiding wound-infection are known, conservative surgery will 
be practised much more than was possible heretofore. Gunshot fractures 
of the long bones and joints may be treated conservatively when the main 
trunks of nerves and blood-vessels have sustained no serious injury, when 
the wound is aseptic, and when the soldier remains with his friends. 
Even though he should have to wait a day or more and be moved about 
before finding a place of rest where treatment may begin, if his wounds 
remain uninfected recovery without amputation or resection may be ex- 
pected. But when the case has to be left in the hands of the enemy, 
where neglect and infection are certain to follow, the chances of the suf- 
ferer may be more favorable with a good primary stump permanently 
dressed than with a severe compound fracture which will probably result 
in suppuration and secondary amputation at the best. 

Laparotomy for gunshot wounds of the abdominal viscera, unlike many 
other operations in military surgery, will always be greatly restricted in 
its application and usefulness by the very exacting conditions necessary to 
success. Wounds of the viscera do not admit of delay. There is no way 
to prevent sepsis, as in external wounds. The time that may elapse before 
an operation must be done is limited to from three to five hours, after 
which the chances of success diminish very rapidly. The operation must 
be done at the hospital in a warm, quiet room protected from wind and 
dust, with good light, competent assistants, plenty of time, and the ad- 
vantage of the strictest antiseptic precautions. Very exceptional qualifi- 
cations are demanded of the surgeon. None but those having skill and 
especial training in this line, and who have had considerable experience, at 
least on the cadaver and on living animals, should dare undertake it. The 
mortality from laparotomy for gunshot wounds of the intestines done by 
inexperienced operators will be much greater than that under the expect- 
ant plan of treatment. Except in siege operations the hospitals will 
rarely be established in time to offer the benefits of this operation to those 



218 MILITARY SUBGERY AND THE CARE OF THE WOUNDED. 

wounded in the early part of an engagement. Very few of the severely 
wounded will be able to reach the hospital, under ordinary circumstances, 
within five hours after the receipt of their injuries. Men with penetrating 
wounds of the abdomen suifer from shock and hemorrhage, and often 
have to remain for a time on the field, and they usually have to be carried 
long distances on litters. Such cases are brought to the hospital in the 
evening or during the night, when the difficulty of operation is increased 
by the want of proper light, or more frequently not until the following 
day, when it is too late. An operator with the requisite skill and experience 
will rarely be available, and where there are many wounded the services 
of two or three of the best surgeons and an hour or two of precious time 
can seldom be given to the doubtful benefit of one among a number of 
men urgently needing assistance. Battles result in defeat just as often 
as in victory for one side or the other, and among the wounded prisoners 
the benefit of laparotomy will hardly be realized, although some ante- 
mortem abdominal sections may be made by well-meaning surgeons with 
more zeal than discretion. On the whole, the outlook for future opera- 
tive interference in cases of penetrating wounds of the viscera on the 
battle-field is not very promising. But still, there will be exceptional 
cases and especially favorable circumstances where this procedure may 
become practicable. 

After every great battle all the more severely wounded ought to re- 
main and be taken care of as near as possible to where their wounds 
were received. Instead of being moved from place to place and hauled 
about on railroad-cars and steamboats for ten days or two weeks to hos- 
pitals in the cities already crowded and infected with diseased wounds, 
tents and temporary hospital accommodations should be promptly brought 
to the wounded, and they should be left at rest and permanent treatment 
begun at once. They should be turned over to volunteer aid societies in 
order to relieve the military surgeons — who must go on with the army — 
and the best surgeons from civil life should come to attend them. The 
twenty-one thousand wounded after Gettysburg, and those from other 
great battles during the War of the Rebellion, included many serious 
cases that certainly would have done better if they had been treated in 
tents pitched on frames near the field, where they could have remained 
for a time, instead of being moved at once to the general hospitals. 



DISEASES OF THE BONES. 

By NICHOLAS SENN, M. D., LL.D. 



The osseous system is an important part of the human body, as it 
constitutes the framework for the origin and insertion of muscles and 
furnishes protection for all the vital and important organs, while the long 
bones form a complicated system of levers for locomotion and prehen- 
sion. The injuries and diseases of the bones have from time immemorial 
been regarded as surgical lesions, and their treatment, by common con- 
sent, has been assigned exclusively to the surgeon. 

Bone affections are prone to extend from one part to another. The 
progressive involvement of the different tissues by the same disease can 
be readily explained by the intimate relationship of the nutritive con- 
ditions and vascular connections between the different organic constituents 
of bone. The periosteum, bone, and myeloid tissue receive a common 
blood-supply, and the venous blood is returned through the same chan- 
nels. The epiphyseal and articular cartilages receive their nourishment, 
at least in part, from the adjacent bone. The myeloid tissue is of 
interest to the physiologist and the physician, as it is now generally con- 
ceded that it is one of the blood-producing organs and the seat of serious 
pathological changes in myelogenous leukaemia. The different anatomic 
constituents of bone manifest a special predilection for certain conditions 
of malnutrition and infective lesions. 

In osteomalacia quantitative diminution of the earthy salts charac- 
terizes the disease, while in fragilitas ossium the reverse is the case. 
Rickets attacks in preference the bones of the skull and the epiphyseal 
extremities of the long bones. The virus of syphilis attacks more 
frequently the periosteum than bone. Acute suppuration begins almost 
exclusively primarily in the myeloid tissue. Tuberculosis is found most 
frequently in the epiphyseal extremities of the long bones, and in the 
short and flat bones, seldom as a primary periosteal affection except in 
tuberculosis of the ribs. The bone-tissue proper is almost immune to 
any kind of infection, playing a passive role in all acute and chronic 
inflammations of bone. 

To the author has been assigned the task of discussing the affections 
of bone resulting from malnutrition and infection. 

Diseases of the Bones caused by Local ob General 

Malntjtbition. 

The effects of local malnutrition are familiar to every surgeon, because 
this condition appears almost constantly as one of the results of chronic 
joint affections, particularly those of a tubercular character. The atrophy 

219 



220 DISEASES OF THE BONES. 

involves more or less all of the tissues of the affected limb, but is especially 
well marked in the contiguous bones. The atrophy, osteoporosis, and 
increased fragility of the bones follow the joint affection in consequence 
of a combination of causes, the most important of them being inactivity 
and tropho-neurotic influences. 

Serious mistakes have often been made by competent surgeons, in 
operating for chronic joint affections by resection or amputation, by mis- 
taking the atrophy for an extension of the disease from the joint to the 
bones, removing, consequently, too much tissue, often substituting an 
amputation for an intended arthrectomy or resection. 

The effect of a general malnutrition, which makes itself manifest by 
well-marked pathological processes which affect nearly all of the bones 
of the skeleton, is well shown by rachitis, osteomalacia, and fragilitas 
ossium, the three diseases of bone caused by defective or faulty nutrition 
which will now be discussed. 

Eachitis. 

Rachitis (rhachitis, rickets, English disease) is a disease of infancy 
and early childhood. Occasionally it appears as a congenital affection 
(foetal rickets). Uninfluenced by treatment, it pursues a self-limited 
course, its duration varying from one to three years. 

Etiology. — Rickets manifests a predilection for the time of life noted 
for the activity of the physiological processes in general, and those of the 
part affected in particular. The disease is preceded and attended by 
many life-threatening coincident complications, such as diarrhoea, bron- 
chitis, catarrhal pneumonia, pertussis, rubeola, etc., which, owing to the 
general debility of the child, are attended by an alarming mortality. 

The principal factors in the causation of rachitis are insuificient or 
improper food, and diseases of the gastro-intestinal canal which impair 
digestion, absorption, and nutrition. It is most prevalent in large cities, 
badly-ventilated and over-crowded tenement-houses, and in orphan 
asylums. From personal observation it seems that it is much more 
frequent in this country than we have been led to suppose. Very 
recently four cases of genu valgum of rachitic origin, in children from 
three to six years of age, were brought at one time to the St. Joseph's 
Hospital in this city from an orphan asylum in a neighboring city. 
This number constituted only one of the periodical instalments from 
the same institution. I have reason to believe that in this country many 
cases of rickets are not recognized, and the little patients are treated for 
the complications and not for the original disease. As our cities become 
larger and more crowded, and the struggle for existence more severe, 
this disease will become more prevalent, and the surgeons and gynecol- 
ogists Avill be made more familiar with its remote consequences. The 
majority of cases of rachitis are bottle-fed children, and this is the 
reason why the disease is so common in our orphan asylums. Occasion- 
ally the disease develops in children nursing at the breast, but in such 
cases it will usually be found, upon examination of the milk, that while 
the quantity may be adequate the quality is defective. In such in- 
stances a change to artificial feeding is often followed by a speedy 
improvement in the rachitic symptoms and in the general health of the 



RACHITIS. 221 

child. We are forced to accept the fact that rachitis is produced by no 
single cause, but that its true etiology consists in a combination of cir- 
cumstances and conditions which impair general nutrition at a time of 
life when the tissues make a special demand on the nutritive resources. 
It is stated that the intra-uterine form of rachitis has been produced by 
administration of lactic acid through the mother (Heitzmann). 

Symptoms and Diagnosis. — If an infant or young child subjected 
to the influences which we recognize as the most potent etiological factors 
in the production of rickets presents the general appearance of ill-health, 
and at the same time manifests a changed disposition, if it is peevish 
and restless, a careful examination for rickets should be promptly insti- 
tuted. A more careful inquiry into the clinical history of the case will 
usually elicit the fact that sleep is disturbed ; the child's forehead and 
scalp are covered by a profuse perspiration, especially during the night ; 
the little patient kicks off the covering during the night ; more or less 
disturbance of digestion accompanies these symptoms. If the dis- 
ease has existed for some time, as is generally the case when the physi- 
cian's services are sought, unmistakable evidences of its existence are pre- 
sented by the characteristic changes which it has produced in certain parts 
of the skeleton. The bones of the cranium are soft and readily yield to 
pressure from without (craniotabes). The anterior part of the skull is often 
found changed in aggravated cases, assuming somewhat of a quadrangu- 
lar shape. The fontanelles are large, and their closure is often delayed 
for a long time. At the junction of the ribs with the cartilages an 
enlargement, something like the provisional callus in a green-stick 
fracture of the clavicle, is readily detected : these enlargements consti- 
tute the so-called " rachitic rosary." The chest is often found flattened 
from side to side with a corresponding projection of the sternum. 

If the child is old enough to sit in an upright position, posterior 
curvature of the spine is often present, which has been repeatedly mis- 
taken for tubercular spondylitis. Lateral curvature is also often trace- 
able to yielding of the softened bodies of the vertebrae. The most 
characteristic changes, however, are found in the long bones at a point 
corresponding to the epiphyseal cartilages. Here the bone is decidedly 
enlarged and tender on pressure during the active stage of the disease. 
The unequal development of the condyles of the femur gives rise to 
an abnormal direction of the articular surface of the femur, resulting 
either in genu valgum or genu varum, the former being much more 
frequent than the latter. 

The ligaments of joints are relaxed, permitting an abnormal range of 
motion. Owing to the general softening of the bones the shafts of the 
long bones yield to muscular traction or the superimposed weight of the 
body, and bending or even infraction upon slight application of force 
takes place, resulting often in material shortening of the Hmbs and per- 
manent deformity. The rachitic pelvis is an object of great interest to 
every obstetrician. 

Prognosis. — The intrinsic tendency of the disease is to recovery in 
the course of from one to three years. Many children succumb to inter- 
current affections. The prognosis is favorable if the disease is recog- 
nized in its inoipiency and an early rational treatment is instituted. 
It is astonishing to what extent the deformities caused by rachitis are 



222 



DISEASES OF THE BONES. 
Fig. 271. 







Longitudinal section of ossifying margin of a long bone in rickets : a, proliferating cartilage-cells, 
the area of proliferation very greatly extended and the arrangement quite irregular; 6, b, cal- 
cification of the cartilaginous matrix at different levels, but not followed by formation of me- 
dullary cavities. The formation of medullary cavities (e, e) and of bone is occurring quite 
irregularly, the level being higher at the right (c) than at the left (c). At d the osteoblasts are 
forming bone. In Various places, especially at d, pieces of cartilage are seen in the midst of 
bone, and an apparent transition of the one into the other is seen. X 90 (Thierfelder). 



RACHITIS. 223 

often corrected spontaneously after the subsidence of the acute symp- 
toms. 

Patholog-y and Morbid Anatomy. — Sections of I'achitic bone under 
the microscope show everywhere errors and defects of ossification (Fig. 
271). The most conspicuous feature of the microscopic picture is the 
enormous exaggei'ation of the zone of multiplication of the cartilage- 
cells. Among them we find no definite histological purpose, and no 
regular arrangement as seen in normal bone-growth. The bone through- 
out, but especially in the immediate vicinity of the epiphyseal cartilages, 
is exceedingly vascular. The osteoblasts under the influence of a rich 
blood-supply secrete masses of osteoid substance, but deposition of earthy 
salts fails to take place, resulting in osteoid tissue and bone-cartilage 
without lime salts. This imperfect ossification accounts for the softness 
and osteoporotic nature of rachitic bone. In a similar manner are the 
growth and development of the periostevnn and perichondral tissue inter- 
fered with : we find here also a rich vascular supply and osteoid tissue. 
The new cancelli of bone do not present a normal arrangement, but ai'e 
disposed of in an irregular manner, without a definite architectural plan, 
as is the case in normal growth of bone. Myeloid spaces form in the 
cartilage, still more increasing the osteoporosis and diminishing the 
resistance of the bone. That the earthy salts destined to complete the 
ossification are not thus utilized, but are eliminated through the kidneys, 
is evident from their presence in large quantities in the urine of rachitic 
children. 

Upon the cessation of the active symptoms, either spontaneously or 
under appropriate treatment, a change is observed in the tissues of the 
bone-growing centres. The osteoid tissue is promptly converted into 
bone tissue by the deposition of the inorganic constituents, and bone is 
now produced in excess. Osteosclerosis takes the place of osteoporosis. 
The rachitic bones are heavier than normal • bones, their compact layer 
being abnormally thick and dense. With the process of ossification 
vascularization is diminished, as well as the myeloid tissue, rendering 
the bones heavy and exceedingly dense. Excessive ossification of the 
bones of the face and skull, known heretofore as leontiads ossea, is 
occasionally observed as one of the results of rickets. Sutton regards 
leontiasis ossea as a modification of rickets. He reports a case in a 
young man aged twenty-four. The pathological changes of the skull in 
this case are shown in Fig. 272. 

Treatment. — The general treatment of rachitis consists of the 
employment of such measures as are calculated to restore normal 
nutrition. A proper diet and the enforcement of hygienic instructions 
are the most important part of the general treatment. Pure sterilized 
milk, eggs, oysters, oatmeal gruel, cracked wheat, raw or rare roast beef, 
according to the age of the child, are the most appropriate articles 
of diet. Plenty of sunlight, fresh air, and , salt baths will materially 
hasten recovery. A change of climate will often do more than anything 
else toward the improvement of the general health, and in obstinate cases 
should always be recommended. If digestion is impaired, this condition 
must receive special attention. Contrary to expectation, the adminis- 
tration of lime salts has proved of little avail. The researches of 
Kassowitz have established the therapeutic value of minute doses of 



224 DISEASES OF THE BONES. 

phosphorus in the treatment of this disease. It should be given in an 
emulsion of cod-liver oil. Arsenic in small doses has also proved of 
value. During the acute stage of the disease the patient should not be 
allowed to sit, stand, or walk, in order to guard against the occurrence 

Fig. 272. 




Leontiasis ossea. 



of deformities. If deformity is found present during this stage, further 
aggravation can be prevented successfully by an efficient mechanical sup- 
port. Plaster-of-Paris dressing and plastic splints answer an excellent 
purpose in such cases. 

The treatment of confirmed deformities, after the disease is under con- 
trol and ossification has taken place, must be in accordance with estab- 
lished rules of orthopaedic surgery. Systematic, well-regulated gymnas- 
tic exercise is indicated in deformities of the chest. Curvature of the 
long bones, sufficient in degree to warrant surgical interference, should 
be treated by osteoclasis. Supra-condyloid linear osteotomy should be 
resorted to in cases of genu valgum beyond the reach of manual redresse- 
ment. I have invariably operated on both limbs at the same time, and 
have never observed any ill results from the operation. The fractures 
always united promptly by bony callus, without any disturbance in the 
adjacent knee-joint and without any superabundant amount of callus. 
A small incision is made through the intermuscular septum over the pro- 
posed line of osteotomy, down to the bone, when the soft tissues are 
retracted, and the section through the bone made with a Macewen chisel 



OSTEOMALACIA. 225 

sufficiently far to complete the fracture by manual force. Some care is 
required in avoiding injury to the popliteal vessels. The little wound is 
closed by a row of buried and superficial catgut sutures, when the limb 
is brought into proper position and immobilized in a circular plaster-of- 
Paris dressing extending from tlie base of the toes to the groin. Between 
the limb and the plaster splint a thick la}er of antiseptic cotton should 
be interposed to guard against localized decubitus and harmful circular 
constrictions. This dressing is not removed for six weeks. At this time 
the process of repair is nearly completed, and the union is firm enough 
to render further mechanical support superfluous. Genu varum is cor- 
rected by osteoclasis, supra-condyloid linear osteotomy, or a cuneiform 
osteotomy of the tibia from two to three inches below the knee-joint, 
according to the degree and location of the curvature. 

Osteomalacia. 

Osteomalacia (malacosteon, mollities ossium) is a disease affecting the 
adult skeleton, and, as the different names indicate, characterized by 
softening of the bones. It differs from rachitis, however, in that it pro- 
duces softening of normal bone, while the latter prevents temporarily 
ossification of the soft fcetal bones. 

Etiology. — Osteomalacia is met with most frequently in childbearing 
women, either during pregnancy or lactation. Oppenheimer states that 
91 per cent, of cases of this disease are met with in women, 70 per cent, 
in those pregnant. It is seldom found in the male or the non-puerperal 
state. Statistics show that it is more prevalent in some sections of a 
country than others. In Germany, for instance, nearly all cases occurred 
in the western part. In this country it is exceedingly rare ; only a few 
well-authenticated cases have been reported. In some cases it has been 
shown to be hereditary. The essential cause is unknown. 

Symptoms and Diagnosis. — The actual development of the disease 
— that is, the bending and fracture of bones — is preceded by certain pre- 
monitory symptoms. Failure of the general health and wandering pains 
in the affected bones, usually attributed to rheumatism, are among the 
first symptoms to appear. The urine contains a great abundance of 
phosphate of lime, which, as shown l)y Mr. Solly, is removed from the 
bones and eliminated through the kidneys. Another abnormal element 
of the urine is hydrated deutoxide of albumin, which Dr. Bruce Jones 
found present in one case in the proportion of 66.97 : 1000. In the 
pregnant and nursing woman the disease begins in the bones of the pel- 
vis ; in the male and in the non-puerperal woman, in the sj^inal column 
and bones of the chest. Bending or fracture of the long bones occurs 
according to the existing pathological conditions. If the softening is 
limited to the interior of the bones, and only a thin shell of the com- 
pacta remains, fracture results. These fractures are produced by the 
slightest application of force, as lifting the patient out of bed or shifting 
the position in bed. The fractures in advanced cases are usually multi- 
ple. Mr. Tyrrell reports a case with twenty-two fractures, and Mr. 
Arnott another with thirty-one. If the compacta of the long bones is 
likewise softened, the bones bend, the limbs become shortened and 
twisted in all possible shapes. The bones of the head usually remain 

Vol. ir— 15 



226 



DISEASES OF THE BONES. 



intact — another point of importance in the differential diagnosis between 
this disease and rachitis. 

Rheumatism and malignant disease of the bones are the affections 
most likely to be mistaken for osteomalacia. Carcinoma and sarcoma 
seldom involve more than one bone, and in the former the primary 
tumor in another organ can usually be discovered. The pain in osteo- 
malacia is always referred to the seat of the bone lesions, and not to 
joints. The exclusion of rheumatism is a matter of no great difficulty. 
Multiple osteomyelitis is attended by fever, and not infrequently by 
joint complications. 

Prognosis. — In the puerperal form a spontaneous cure has been 
observed after the expiration of the puerperal period and cessation of 
lactation. In the non-puerperal form no such favorable change is to be 
expected. Life is often prolonged for many years, when death finally 
results froin exhaustion. The fractures evince little or no tendency to 
bony consolidation, and spontaneous correction of the deformities caused 
by bending of the bones never occurs. 

Pathology and Morbid Anatomy. — The essential pathological pro- 
cess in osteomalacia consists in decalcification of the affected bones (Fig. 
273). By an unknown chemical process the earthy salts are dissolved, 

Fig. 273. 




A fragment of bone from a case of osteomalacia. The central part shows the usual appearance 
of bone, while the marginal parts are transparent, being devoid of lime salts, although still 
showing bone-corpuscle. X 90. 

removed from the parts by the blood-vessels, and eliminated through the 
kidneys. The solution of the lime salts occurs primarily in the portions 
of the bone next the medullary spaces and Haversian canals, so that if 
the bone is examined the central parts of the trabeculse are seen to be 
opaque like normal bone, while the peripheral parts are decalcified. The 
medullary tissue also undergoes alteration ; the fatty tissue is replaced by 



FRAOILITAS OSSIUM. 227 

round-cells. This change in the myeloid tissue undoubtedly accounts for 
the absence of callus at the seat of fracture. 

Treatment. — The general treatment should aim at the removal of 
the primary cause. In pregnant women it would appear to be justifiable 
to interrupt gestation. Lactation should be arrested upon the appearance 
of the first symptoms. Whether the internal use of phosphorus is of any 
value in arresting the disease has not been sufficiently ascertained by 
clinical experience. A generous diet and hygienic measures are always 
indicated. In severe cases the patient should always be placed upon a 
water-bed and handled with great care. Fractures should be treated 
upon general principles, and bending of bone prevented by the use of 
light, comfortable retentive dressings. In three cases Fehling has 
removed the ovaries, and recommends such operation in the non-pregnant 
state, and Porro's operation when the uterus is gravid. Fehling's ope- 
ration has found a number of warm advocates, and has yielded encourag- 
ing results. Whether castration in man would exert the same influence 
in arresting the disease remains to be determined by future experience. 

Feagilitas Ossium. 

Fragilitas ossium (osteopsathyrosis) is a bone affection in which the 
pathological conditions are the reverse of those described as characteristic 
of osteomalacia ; that is, the proportion of inorganic to the organic con- 
stituents is in favor of the former, rendering the affected bones abnor- 
mally brittle. The nutritive disturbance manifests itself by an apparent 
increase of the earthy salts, with elimination of the cellular elements and 
diminution of vascularization. The essential cause of this disease is 
unknown, but many clinical facts point to disturbed or imperfect inner- 
vation. The gross appearances of the bones do not indicate any well- 
marked pathological changes. In a case mentioned by Mr. Stanley " a 
portion of the recently-fractured femur exhibits a thinning of its walls 
from the absorption of its inner laminse, but without softening of its 
texture ; it retains the hardness of healthy bone." 

The fragility varies greatly in degree. If the disease is well estab- 
lished and far advanced, fractures occur from the most trivial causes ; 
multiple fractures of the long bones constitute, therefore, the most con- 
spicuous clinical feature of this disease. It affects males and females of 
different ages. Landerer reports the case of a man twenty-three years 
of age who had suffered eight fractures, in each instance the fracture 
being the result of an insignificant injury. Planchard mentions a girl 
twelve and a half years old who came under his observation who had 
sustained forty-one fractures. Heredity is acknowledged as one of the 
etiological factors. An instance is mentioned by Pauli in which, for three 
generations, certain individuals of a family have suffered from extraor- 
dinary fragility of the bones. 

Fragilitas ossium has been observed as a complication in some forms 
of insanity, and as the result of long confinement in bed incident to other 
chronic ailments. The general health is usually not much impaired unless 
the disease is associated with antecedent or intercurrent affections. 

The increased brittleness of bone is not incompatible with prompt 
and perfect repair of a fracture. In some instances it has been 



228 



DISEASES OF THE BONES. 



observed that bony union occurred in a shorter time than under ordinary 
circumstances. In other cases general nutrition is so much impaired 
that callus-formation is imperfect or entirely wanting. The usual treat- 
ment for fractures should therefore always be instituted in such cases 
with a view of obtaining bony consolidation of the fracture with the 
limb in good position. Long confinement in bed should be avoided by 
the use of plastic circular splints, which will enable the patient within 
a few days after the accident to avail himself of the benefits of out-door 
air and exercise. The general health of the patient should be improved 
by appropriate diet and favorable hygienic and sanitary surroundings. 
Markoe advises the internal use of iodide of potassium in cases of 
defective callus-production. 



Fig. 274. 



Osteitis Deformans. 

This bone affection was first described by Sir James Paget in 1877. 
The clinical aspects and pathological changes of this form of non-sup- 
purative inflammation of bone are well given in this author's own 
language : " This form of chronic osteitis begins in middle age or later, 
is very slow in progress, may continue for several years without influ- 
ence on the general health, and give no other trouble than those which 
are due to the changes of shape, size, and direction of the diseased bone. 
Even when the skull is largely thickened and all the 
bones exceedingly altei'ed in structure, the mind 
remains unaffected. The disease affects most fre- 
quently the long bones of the lower extremities and 
the skull, and is usually symmetrical. The bones en- 
large and soften, and those bearing weight yield and 
become unnaturally curved and misshapen, suggest- 
ing the proposed name, osteitis deformans (Fig. 274). 
The spine, whether by yielding to the weight of the 
overgrown skull or by change in its own structures, 
may wilt and seem to shorten, with greatly increased 
dorsal and lumbar curves ; the pelvis may become 
wide ; the necks of the femurs may become nearly 
horizontal. But the limbs, however misshapen, re- 
main strong and fit to support the trunk. In its 
earlier periods, and sometimes through all its course, 
the disease is attended with pains in the affected 
bones — pains widely various in severity and variously 
described as rheumatic, gouty, or neuralgic — not es- 
pecially nocturnal or periodical. It is not attended 
with fever. No characteristic conditions of urine or 
fseces have been found in it. It is not associated 
with any constitutional disease, unless it be cancer. 

" The bones examined after death show the con- 
sequences of an inflammation, affecting in the skull 
the whole thickness, in the long bones chiefly the 
compact structure of their walls, and not only the 
walls of their shafts, but in a very characteristic manner those of their 
articular surfaces. 




Osteitis deformans : 
sections of tibia 
and patella. 



i:XOSTOSIS. 229 

" The changes of structure produced in the earliest periods of the 
disease have not been observed, but it may be believed that they are 
inflammatory, for the softening is associated with enlargement, with 
excessive production of imperfectly developed structures, and with 
increased blood-supply. 

" Whether inflammation, in any degree, continues to the last, or 
whether, after many years of progress, any reparative changes ensue, 
after the manner of a so-called consecutive hardening, is uncertain." 

This lifelike description of the most important clinical features and 
gross pathological changes of this disease, given by one of the pioneers of 
surgical pathology, would indicate that this disease is more closely allied to 
the class of bone diseases caused by nutritive changes than to inflamma- 
tory processes, as they are understood at the present time. The absence 
of high temperature and other symptoms of inflammation would cer- 
tainly tend to confirm such an origin. That the disease may remain lim- 
ited to one or two bones has been shown by a number of clinical obser- 
vations. Bowlby calls attention to a case lasting ten years, in which, 
contrary to the rule, but a single bone — the femur — was affected. The 
patient was a sufferer from gout, and there was associated osteoarthritis 
of the hip- and knee-joints. Humphrey describes a case in which the 
bones of the upper limbs were affected, while the bones of the lower 
extremities showed very little trace of the disease. The disease, like 
other bone affections caused by faulty nutrition, is sometimes hereditary. 

Maguire mentions the fact that one of Paget's original five cases lived 
to be over seventy years of age, and that two sisters of this patient began 
to show signs of the same disease. Hutchinson, in speaking of this 
form of bone disease, says that it is a disease chiefly of senile periods of 
life ; that it may occur in either sex, but is more frequent in men ; that 
it often happens to those who have a gouty family history ; that it is 
probably more common in England than elsewhere ; that it consists of 
a process of osteitis and periostitis, attended by the abundant formation 
of ill-developed new bone and the breaking to some extent of the old ; 
that it is often in the early stages restricted to one bone ; that it tends in 
all cases to become generalized, involving all the bones of the body ; that 
it has no connection with syphilis, although it may be simulated by it ; 
that it pursues a chronic course. 

The treatment of Paget's disease of the bones in the absence of any 
known special cause must be directed mainly toward the improvement 
of the general health of the patient. As osteitis deformans resembles in 
many respects rickets, it is possible that the internal administration of 
small doses of phosphorus or arsenic may prove of value in its treatment. 

Exostosis. 

Another afl'ection of bone caused by local errors of nutrition is 
exostosis. By this term is meant a localized hypertrophy of bone to 
distinguish it from osteoma or bone tumor. Osteomata, or true bone 
tumors, are most frequently met with in connection with the bones of 
the cranium and face, while exostosis affects in preference the epiphyseal 
extremities of the long bones. In these localities the exostosis appears 
in the form of swellings which spring from the epiphyseal line, and are 



230 



DISEASES OF THE BONES. 



composed of cancellated tissue covered by a very thin layer of compact 
tissue. Virchow applied to this affection the term " enchondrosis ossi- 
ficans." Favorite localities are the inner surface just above the condyle 
of the femur, the head of the tibia, or phalanges of the fingers and toes. 
Mucous bursas sometimes form on the surface of the swelling, which has 
given rise to still another name by which such swellings are known — 
viz. exostosis bursata. According to Eindfleisch, such bursse are pro- 
longations from the articular synovial membrane. While in some in- 
stances such a direct communication exists between bursse and adjacent 
joints, in the majority of cases the bursa develops as a new structure on 
the surface of the swelling, in which event no direct communication exists 
between it and the adjacent joint. Frequently the surface of such swell- 
ings is covered by a thin layer of cartilage. The surface is often very 
irregular, showing the efiect of pressure upon their growth (Fig. 276). 

Fig. 275. 





Exostosis of head of tibia. 



This affection is often multiple. Clark reports a case in which all 
bones of the body, with the exception of the bones of the skull, were 
aifected. Pick describes a case with 194 exostoses; Leidy, with 126; 
Lagroux, with 50 ; Charboux, with 40 ; and in Campbell's case they are 
said to have been innumerable. I have observed a case in which both 
upper ends of the femora were affected to such an extent as to interfere 
materially with the free motion of the hip-joints. 

Many authors regard this form of exostosis as a circumscribed, mod- 
ified form of rickets in the adult. It appears to be hereditary to a certain 
extent. Charboux calls attention to a case of transmission of this affec- 
tion from father to son and from the son to four grandchildren. Maclean 
describes six cases of multij)le cancellous exostoses occurring in the same 
family. Heredity was manifestly present, but there was nothing to sup- 
port the idea that the disease was of syphilitic or rheumatic origin or 



INFECTIVE DISEASES OF THE PERIOSTEUM AND BONE. 231 

that it was due to the effects of intermarriage. There were some evidences 
of rickets. Bessel-Hagen claims that multiple exostoses cause disturb- 
ances in the growth of bone. Rubinstein, however, is not inclined to 
accept the view that a direct relation exists between the size of the exos- 
tosis and the decrease in the growth of bones. Schiiller believes that the 
condition is not one of primary retardation of growth, but one of primary 
overgrowth, in which all growth ceases sooner than under ordinary cir- 
cumstances. Orlow maintains that exostosis bursata springs from the 
epiphyseal cartilage, the bursa being of secondary origin. Lagroux agrees 
with Vix that these exostoses may be the result of exaggerated bone- 
production incident to a recovery from rickets. Exostosis often results 
in impairment of function by the swelling interfering with free motion 
of adjacent joints or the action of important muscles ; in other more rare 
instances the pressure upon important vessels may result in grangrene. 
Innes reports a case in which exostosis of the head of the tibia (Fig. 5) 
caused gangrene of the foot and leg by pressing on the arteries. Braun 
saw apparent complete ankylosis of the hip caused by an exostosis nine 
inches in length extending downward from the anterior superior spine 
of the ilium. 

Treatment. — As exostosis of the cancellous variety is preceded by a 
cartilaginous and osteoid stage, it would appear that any therapeutic agent 
which would favor ossification would exert a tendency to the limitation 
of the growth. This disease in its active stage almost exclusively affects 
young adults before ossification has been completed. For these reasons 
I am inclined to believe that antirachitic remedies, notably phosphorus 
and arsenic, would prove useful in limiting the growth of the swelling 
by causing an early transition of immature into mature tissue. 

Operative removal is only indicated when the growths interfere 
with joint-function or produce harmful pressure. In either of these 
events complete removal must be effected by operative measures. From 
the fact that these swellings are in very close proximity to joints, and 
occasionally at least are in communication with them through an overlying 
bursa, aseptic precautions must be followed out in performing the opera- 
tion, as otherwise a serious and often life-threatening suppurative arthritis 
might follow. After free exposure of the base of the swelling it is sev- 
ered from the shaft of the bone by a chisel. After careful hsemostasis 
the wound is closed by suturing throughout. Immobilization and abso- 
lute rest of the limb must be secured until the wound is healed. 

Infective Diseases of the Periosteum and Bone. 

The list of infective diseases of the periosteum and bone is con- 
stantly growing longer. Some of the affections which I have included 
among the diseases resulting from abnormal or defective nutrition will 
undoubtedly soon have to be included under this heading, as their micro- 
bic origin will be demonstrated by future observation and research. The 
inflammatory affections of the bone and its envelope are characterized by 
certain pathological processes which distinguish them from the diseases 
caused by malnutrition and regenerative processes. In all inflammatory 
diseases more or less of the new material is destroyed and lost, while in all 
reparative processes the new cellular elements are utilized in the formation 



232 DISEASES OF THE BONES. 

of new tissue. In all infective lesions of the bone and its fibrous invest- 
ment, unless caused by an infection through an open wound communicating 
with the periosteum or bone, the microbes reach the seat of the disease 
through the circulation, localize in the part predisposed, and produce there 
their pathogenic action. The microbes — or, rather, their toxic products — 
destroy more or less of the exudate which then constitutes the specific 
pathological product, and the macroscopical appearance of which often 
furnishes an indication of the character of the microbial invasion. The 
microbes which are known to be the direct cause of infective diseases of 
the bone and its envelope, the periosteum, are — 1, pus-microbes ; 2, bacillus 
of tuberculosis ; 3, unknown microbe of syphilis ; 4, actiuomyces. The 
pyogenic microbes produce suppurative lesions, while the remaining mi- 
crobes, when present in a pathogenic quantity, possess the intrinsic power 
of converting mature into granulation tissue. The pathological product 
of the latter, being composed primarily largely of granulation tissue, was 
termed by Virchow, years ago, " granuloma." The pus-microbes produce 
an acute suppurative inflammation, while the aifections caused by the 
remaining microbes are clinically characterized by their chronicity. 

Periostitis. 

Inflammation of the periosteum should be classified according to its 
microbic cause into — 1, suppurative; 2, tubercular; 3, syphilitic; 4, 
actinomycotic. 

Suppurative Periostitis. — Primary suppurative periostitis is an exceed- 
ingly rare disease. It usually occurs as a secondary affection in the 
course of osteomyelitis. Traumatic periostitis, without invasion of pus- 
microbes, does not occur. The regenerative processes in the periosteum 
following an injury are constantly being mistaken for inflammation, and 
are treated upon this wrong supposition. Without microbes there can 
be no periostitis. A great deal of harm has followed the practice of 
surgeons who persist in regarding suppurative periostitis as a common 
primary disease. The treatment adopted upon this ground is not adapted 
for the primary osteomyelitis which precedes it. Extensive necrosis, 
serious joint-complications, pyaemia, and death are some of the conse- 
quences which follow such a wrong diagnosis and the treatment adopted 
to meet the indications of a secondary disease in place of the original 
affection — the osteomyelitis. 

In the exceptional cases in which suppurative inflammation of the 
periosteum occurs as a primary affection the periosteum becomes exceed- 
ingly vascular ; pus accumulates between it and the underlying bone. 
The compact layer of the denuded bone is implicated in the infection, 
and superficial necrosis is a frequent result. Swelling appears almost 
in the beginning of the disease, while in secondary periostitis it is 
a later manifestation. Pain and tenderness correspond in extent to the 
area of infection. Both the local and general symptoms are less intense 
than in cases of osteomyelitis. Early and free incisions under strict 
antiseptic precautions will not only promptly remove pain, but M'ill also 
limit the extension of the disease alon^ the periosteum and adjacent 
structures. 

Periostitis Albuminosa. — Oilier describes a form of acute periostitis 



PERIOSTITIS. 233 

which from the character of the inflammatory product he wished to 
distinguish from the ordinary suppurative form, and gave it the name 
periostitis albuminosa. Instead of pus, the inflammatory material was 
of a serous, viscid, or albuminous appearance. Modern writers, how- 
ever, by more extended clinical observations and careful bacteriolog- 
ical investigations, are inclined to disregard the pathological distinc- 
tion established by Oilier. Schlange reported four cases of albuminous 
periostitis in addition to eleven previously observed by different authors. 
All of the patients were young, between fifteen and twenty years old. 
There was no pus, but a serous synovia-like fluid with evidences of 
inflammation in and around the bone. He regards the disease as a 
form of acute suppurative osteomyelitis, of less intensity than ordi- 
narily seen. Roser regards it as a mistake to create, with Oilier, a 
new variety of periostitis on account of the presence of a known exu- 
dation, inasmuch as he has found such exudation in connection with 
osteomyelitis and tubercular periostitis, and thinks that the presence 
in certain cases of serum or bloody serum containing fat-globules is 
not sufficient to place on a permanent basis the doctrine of a special 
pathological or etiological form of periostitis, as is claimed by Oilier 
for the albuminous variety. 

Jaksch describes a case of periostitis albuminosa, which the clinical 
course, as well as the bacteriological investigation, proved to be a modified 
form of acute osteomyelitis. Schranck collected 32 cases of so-called 
periostitis albuminosa. In the albuminous exudate were found, on 
microscopic examination, flocculi of fibrin, and in its meshes white and 
red blood-corpuscles, globules of fat, nucleated cells, and detritus ; also 
masses of granulation tissue composed of round-cells in varying stages 
of fatty degeneration. Both layers of periosteum were thickened and 
cederaatous. In both of Schrank's cases pus-corpuscles were present, 
but in small quantity. In this variety the symptoms are less acute and 
intense than in the ordinary form of secondary suppurative periostitis fol- 
lowing acute osteomyelitis. In one of his cases he had reason to believe 
that the periostitis was primary. The temperature is rarely very high, 
and the general disturbance is comparatively mild. It has been observed 
most frequently in the diaphyses of the long bones, and in preference in the 
bones of the lower extremities near the epiphyseal cartilages. As com- 
pared with ordinary supjjurative periostitis, the swelling is at first diffuse ; 
later, more circumscribed. The skin is at first unchanged ; later it pre- 
sents a reddish or bluish discoloration. The disease terminates in a few 
weeks or it may be prolonged for several years. If necrosis of the bone 
occurs, the sequestrum is of a greenish color, and the cavity in which it 
lies is lined with gold-yellow granulations. All the conditions resemble 
in every respect ordinary suppurative periostitis, only pus is absent. In 
one case Albert examined the exudate chemically and found mucin. Garrfe, 
Schlange, and Legiehu found in the exudation the stapliylococcus pyogenes 
aureus and made cultivations. Schranck cultivated pus-microbes from the 
exudate of both of his cases. Vollert believes that in these cases suppu- 
ration is present at first, but that the exudate later undergoes a change, 
caused by degeneration of its histological elements. Schlange regards the 
disease as a modified form of osteomyelitis. He believes the difference 
between the exudates is not one in kind, but one of degree. Rosenbach 



234 DISEASES OF THE BONES. 

produced such a form of osteomyelitis artificially in a rabbit. A diminished 
virulence of the pus-microbes furnishes the most plausible explanation. 
Suppurative osteomyelitis shows great differences in reference to the 
virulence of the infection. I have seen numerous cases of osteomyelitis 
in which later infection of additional bones in the same individual did 
not give rise to suppuration, the exudate being of a serous or albuminous 
character, while in other instances the final infection resulted in the pro- 
duction of new bone without loss of tissue, a plastic taking the place of 
a destructive osteomyelitis. 

I have observed several cases of osteomyelitis in which the secondary 
periostitis answered to OUier's description of periostitis albuminosa. All 
of the patients were young persons, and in most of them the posterior 
surface of the femur was the seat of disease. I fully concur with those 
authors who regard albuminous periostitis as a secondary periostitis fol- 
lowing in the course of a modified mild form of osteomyelitis. 

Tubercular Periostitis. — Periosteal tuberculosis of the long bones is a 
comparatively rare affection, being far less frequent than the syphilitic 
variety. As a primary disease it involves most frequently the vertebrae, 
ribs, cranium, and bones of the face. In the last locality it attacks the 
orbital border of the malar bone most frequently. As a secondary affec- 
tion in tuberculosis of the long bone it develops most frequently in con- 
nection with the diffuse infiltrating form of osteotuberculosis. In tuber- 
culosis of the ribs the disease starts most frequently in the periosteum, 
and the bone is gradually destroyed from without inward. The compact 
layer of the ribs at points corresponding to the disease in the periosteum 
shows, at first, minute circumscribed defects, which gradually enlarge, 
imparting to the bone a honeycomb appearance. The disease often 
destroys the continuity of the bone, giving rise to a pathological fracture. 
It not only spreads in the direction of the bone, but also, by continuity, 
along the periosteum, terminating frequently only with the destruction 
of the entire periosteal envelope. The periosteum being the primary 
starting-point of the disease, extension of the process to the tissues out- 
side of the periosteum is an early occurrence. In this locality the disease 
is usually a painless affection. The patient often neglects to seek medical 
advice until he is alarmed by the appearance of a swelling, wliich upon 
examination is found to be a tubercular abscess in connection with a 
tubercular periostitis and osteomyelitis of one or more ribs. In the 
adult, tubercular spondylitis is most commonly the result of extension 
of the disease from the periosteum. A number of vertebrae are attacked 
simultaneously or in rapid succession, and the formation of a tubercular 
abscess sooner or later must be expected. Curvature of the spine is 
frequently absent, and when present it is not as angular as when the 
disease attaclvs primarily the body of one or more of the bones. 

Primary tuberculosis of the periosteum of the cranial bones often 
leads to extensive necrosis of the external table of the skull, while in 
primary tuberculosis of the cranial bones the entire thickness of the 
bones is involved from the beginning. As a secondary disease in tuber- 
culosis of the long bones it is rare, except in the diffuse variety. When 
the dry, granulating focus reaches the periosteum, a small, soft, elastic, 
limited granulation swelling forms, first under, later outside of, it. It 
is characterized by slow growth, comparatively little pain, slight tender-. 



PERIOSTITIS. 235 

ness, and a tendency to remain stationary for a long time. If, however, 
the central focus has become cheesy, and the liquefied, cheesy material 
comes in contact with the periosteum and paraperiosteal tissues, a tuber- 
cular abscess forms in a short time. As soon as the periosteum has been 
perforated the cheesy material infects the connective tissue, which then 
takes an active part in the formation of the tubercular abscess. The 
periosteum ruptures spontaneously ; the skin overlying it becomes tuber- 
cular, and presents subsequently, at the point of perforation, the appear- 
ance of lupus. The bones of the pelvis are occasionally the seat of 
diffuse primary tuberculosis of the periosteum, which is usually followed 
by the formation of large tubercular abscesses, which when incised or 
after spontaneous rupture are followed by mixed infection, profuse sup- 
puration, hectic fever, and often death. 

In the differential diagnosis between tubercular and syphilitic peri- 
ostitis the character of the swelling is of great importance. In the 
former central softening is of frequent occurrence, and takes place 
earlier than in the latter ; at the same time pain and tenderness are not 
as well marked as in syphilitic gumma of the periosteum. 

Treatment. — -The general treatment in tubercular periostitis is the 
same as in cases in which the same disease is located in other organs — 
viz. the improvement of the general health by a liberal and nutritious 
diet, appropriate hygienic measures, change of climate, and the employ- 
ment of remedies which are known to possess anti tubercular properties, 
notably guaiacol and syrup of iodide of iron. If the periostitis has led 
to the formation of a subcutaneous abscess, the same should be evacuated 
by tapping, the debris in its interior washed out by irrigation with a 
saturated solution of boric acid, after which, according to the age of the 
patient, from two to eight drachms of 10 per cent, iodoform in glycerin 
are injected. This little operation should be made under strict aseptic 
precautions, and repeated every week or two. If the tubercular 
abscess has been opened intentionally or accidentally, and a fistulous 
opening has formed, the employment of iodoform injections will no 
longer prove of value. In such cases the diseased part should be 
exposed by an incision if accessible to treatment, and all diseased tissue 
removed by the use of a sharp Voljimann's spoon. It must be remem- 
bered that the disease invariably has attacked the underlying bone more 
or less ; hence a thin layer of the osteoporotic bone should be removed 
with the sharp spoon at the same time. After rendering the cavity 
thoroughly aseptic, it should be dried and covered with a thin film of 
finely-powdered iodoform or painted over with a 10 per cent, emulsion 
of iodoform in glycerin. Packing for a few days with iodoform gauze is 
preferable to immediate suturing of the wound. The secondary sutures 
can be introduced at the time of operation and tied upon removal of the 
iodoform-gauze tampon. In secondary tubercular periostitis the primary 
bone affection should of course receive prompt and efficient treatment. 

Syphilitic Periostitis. — Syphilitic periostitis appears as one of the 
remote manifestations of syphilitic infection. It belongs to the tertiary 
stage of syphilis. It is often met with in children as an hereditary affec- 
tion. It attacks most frequently the bones of the cranium and the shafts 
of the long bones. A favorite locality is the anterior aspect of the tibise. 
The pain and tenderness are more marked than in tubercular periostitis. 



236 DISEASES OF THE BONES. 

Nocturnal exacerbation of pain is one of the characteristic clinical fea- 
tures of this disease. From a pathological point of view two forms of 
syphilitic periostitis can be distinguished: 1, ossifying; 2, gumma. In 
the ossifying variety the granulation tissue is transformed first into osteoid 
material, and later into bone. The affected bone becomes heavier, the 
compact layer thickened, and the new bone becomes sclerosed. The 
gummatous variety appears in the form of swellings of varying density 
attached to the bone. In some instances the granulations are so soft 
and pulpy that fluctuation can be distinctly felt on palpation, and such 
swellings have often been incised under the belief that they were abscesses. 
If secondary infection with pus-microbes takes place, the granulations 
break down, an abscess forms, and more or less destruction of the under- 
lying bone is sure to take place. 

A careful differential diagnosis between tubercular and syphilitic 
periostitis is essential before adopting a special form of treatment. If 
any doubt remains in the mind of the surgeon, the patient should be 
given the benefit of the doubt by placing him upon active antisyphilitic 
treatment. 

Treatment. — If the disease is recognized in time and subjected to 
appropriate treatment, the relief is prompt and its further extension is 
arrested. The most useful therapeutic agent in the treatment of 
syphilitic periostitis is the potassic iodide, administered, according to the 
age of the patient, in doses of from five to sixty grains four times a day. 
It has been my custom to administer a dose an hour before each meal, 
and the last at bedtime. The drug should be well diluted in distilled 
water. In obstinate cases it may be combined with small doses of cor- 
rosive sublimate. In very urgent and inveterate cases mercurial in- 
unctions should be carried to the point of slight salivation, and followed 
by the potassic iodide. Operative treatment should only be resorted to 
in cases in which the gummatous form is complicated by suppurative in- 
fection, and after the general treatment has been thoroughly carried out. 
It is astonishing how speedily large ulcers following syphilitic periostitis 
granulate and heal as soon as the patient is fully under the influence of 
constitutional treatment. 

Actinomyootio Periostitis. — This variety of periostitis is observed most 
frequently, if not exclusively, in connection with the jaws as an extension 
of the actinomycotic process from a diseased alveolus. The inflammatory 
product consists almost exclusively of granulation tissue, in which the 
minute yellowish-gray granules, the actinomyces, are imbedded. Like 
other chronic granulating processes, it is a comparatively painless affec- 
tion. The granulation tissue is subject to secondary infection with 
pyogenic microbes, which when it occurs results in the formation of a 
complicating abscess. The internal administration of potassic iodide has 
gained some reputation in the treatment of this disease, but the main 
reliance must be placed on a thorough removal of the infected tissues 
with the knife, sharp spoon, and actual cautery. 

Diffuse Acute Suppurative Osteomyelitis. 

Osteomyelitis, medullitis, endosteitis, osteitis, and pseudo-rheumatism 
(Roser) are terms used to designate inflammation of bone. Acute sup- 



DIFFUSE ACUTE SUPPURATIVE OSTEOMYELITIS. 237 

purative osteomyelitis is an expression indicating an acute inflammation 
of the marrow of bone terminating in suppuration. It is an exceedingly 
frequent affection in children and young adults. As a primary disease it 
is seldom met with after the skeleton has become fully developed. The 
traumatic variety was familiar to surgeons before antiseptic surgery was 
practised. It resulted from direct exposure of the medulla to infective 
microbes through an open wound, as in compound fractures, gunshot 
wounds of the bones, resection, and amputation. The so-called spon- 
taneous variety, which will be the principal object in the discussion of 
this subject here, occurs from the same cause, without direct exposure of 
the medulla to infective micro-organisms from without. 

The traumatic variety has been recognized for a long time by sur- 
geons as a distinct and most serious wound-complication, but the spon- 
taneous form, occurring without an open communicating wound, was not 
understood until quite recently. We find no mention of this acute affec- 
tion of bone until 1705, when J. L. Petit gave a description of an acute 
disease of the long bones which corresponds with what we now under- 
stand by osteomyelitis. Similar allusions have been made to it by Gooch, 
Pott, Cheselden, Hey, and Abernethy, some of their descriptions being 
sufficiently accurate to enable us to recognize the character of the lesion. 

Cruveilhier alludes to the remote consequences of this affection when 
he says : " The phlebitis of the bones is one of the most frequent causes 
of visceral abscesses following wounds or surgical operations in which 
the bones are involved." Nelaton suggested for this disease the term 
"osteomyelitis" in 1834. In 1849, Stanley gave an accurate account 
of the spontaneous variety under the title " Suppuration in Bone." In 
1855, Chassaignac applied the term "osteomyelitis" for the first time 
to the spontaneous variety. Among the surgeons who studied the trau- 
matic variety may be mentioned Vallette, Roux, Larrey, Pirogoff, 
Lidell, Allen, and Otis. Hoser, in 1865, on account of the multiplicity 
of the bone affection and the frequency with which the joints are in- 
volved, called the disease "pseudo-rheumatism." 

The infectious origin of traumatic osteomyelitis has been recognized 
for a long time, but the spontaneous form was believed to be purely 
inflammatory until Luecke first called attention to its infectious charac- 
ter. Demme, Volkmann, Schede, and Hueter have added valuable con- 
tributions to the modern literature of non-traumatic acute suppurative 
osteomyelitis. Pasteur spoke of " furuncle of bone," because he found 
in osteomyelitic pus a microbe which he claimed was identical with the 
microbe found in furuncles. The bacteriological researches of Kocher, 
Rosenbach, Passet, Krause, and Kraske have established the fact that 
non-traumatic osteomyelitis, like the traumatic form, is a suppurative 
inflammation of the medullary tissue, caused invariably by infection 
with pus-microbes. 

Primary suppuration in bone begins in the medullary tissue ; hence 
it is not correct to speak of a suppurative ostitis, as is so frequently done 
by English and American authors. Primary suppurative periostitis is 
an exceedingly rare affection ; consequently, osteomyelitis must be con- 
sidered as the most frequent of all inflammatory diseases of bone. The 
medullary tissue of bone in young adults and children is exceedingly 
susceptible to infection with pyogenic microbes. 



238 DISEASES OF THE BONES. 

Etiology. — The causes of , suppurative osteomyelitis in both the 
acute and chronic form are essential and exciting. The essential cause 
is the presence in pathogenic quantity of one or more varieties of 
pus-microbes. Direct extension of a suppurative lesion through the 
medium of lymphatic vessels — or nerve-sheaths, as Rinne suggests — 
may be possible, but such a direct connection between a peripheral sup- 
purating focus and a central osseous lesion of a similar nature can sel- 
dom be demonstrated. Infection usually takes place by pus-microbes 
which have found their way into the circulation from a suppurating 
wound or through the respiratory or intestinal mucous membrane, and 
which localize in the medullary tissue prepared for their reception and 
pathogenic action by anatomical peculiarities of the capillary vessels, or 
by a locus minoris resistentice created by an injury or antecedent patho- 
logical condition. A number of well-authenticated cases have been 
reported where a subcutaneous fracture became the starting-point of an 
attack of osteomyelitis in patients who suffered at the same time from a 
suppurating wound in a part distant and anatomically disconnected from 
the fracture. In such cases it is reasonable and logical to assume that 
pus-microbes enter the circulation and are conveyed by the blood-cur- 
rent to the seat of fracture, where they are arrested and find a favorable 
soil for their reproduction and the exercise of their pathogenic prop- 
erties. 

Such cases are simply the counterpart of what has been accomplished 
by experimentation. Clinical experience and experimental research have 
shown that pus-microbes localize in preference near the epiphyseal lines 
of the long bones. The anatomical peculiarities of the blood-vessels 
near the epiphyseal lines of the long bones and in the myeloid tissue 
also present conditions favorable to localization of floating microbes. 
During the growth of bone the epiphyseal regions are supplied with new, 
growing, and imperfectly-developed capillary vessels. 

Neumann has also called attention to a peculiarity of the capillary 
vessels in the medullary tissue, their calibre being four times greater than 
that of the arterial branches that supply them — another important 
anatomical condition which predisposes to localization of microbes in 
this tissue. 

Histological investigation has likewise shown that the small blood- 
vessels in the medullary tissue are devoid of a proper vessel-wall, and 
appear more like channels or excavations than blood-vessels — another 
condition which must exercise a potent influence in determining mural 
implantation of infected leucocytes under the action of an exciting cause 
or causes. 

As Luecke has shown, and Rinne again asserts, the medullary tissue 
is prepared for the action of pus-microbes by the causes which precipitate 
an attack of some febrile affection, as variola, typhoid fever, scarlatina, 
rubeola, and diphtheria. Keen has given a good account of the bone 
lesions which are prone to follow as sequelse to acute infective diseases. 
He found 69 cases, of which 22 affected the head, 7 the trunk, 6 the 
upper and 42 the lower extremities. In 37 cases the disease followed 
typhoid fever. As to the date of occurrence in 47 cases, 10 were within 
two weeks, 27 from three to six weeks, and 10 some months after the 
fever. Keen's explanation was to the effect that the earlier cases prob- 



DIFFUSE ACUTE SUPPURATIVE OSTEOMYELITIS. 239 

ably resulted from thrombosis, and the later from enfeebled nutrition. 
Trauma, if any, in these cases was always slight. 

Kleriim has made some very interesting investigations concerning 
osteomyelitis as a sequela of typhoid fever, giving at the same time a 
complete historical account of this complication. Occurring under such 
circumstances, Chassaignac called the bone disease " typhus des membres." 
As early as 1835, Maisonneuve called attention to suppurative periostitis 
as a complication of acute infectious diseases. Freund, in 1885, first 
drew an accurate clinical picture of inflammatory aif'ection of bone occur- 
ring as a complication or sequela of typhoid fever. Fiirb ringer could 
find only 5 such cases among 1600 cases of typhoid fever. The bone 
affection usually appears from one to two weeks after the fever has 
abated. 

The osteomyelitis attacks usually the long bones, in preference those 
of the lower extremities. Paget and Helferich have studied with special 
care the clinical course of the bone affection. The swelling is generally 
circumscribed, the overlying skin discolored, real fluctuation rare. The 
disease often pursues a chronic course. The inflammatory product is 
frequently removed by absorption, as sequestration seldom occurs. Among 
the other terminations must be mentioned caseation and liquefaction. 
These complications, from a bacteriological aspect, are either the result 
of infection with the Klebs-Eberth bacillus of typhoid or with pus-microbes 
which appear in the circulation in consequence of a mixed infection 
(Schede) caused by the entrance of the microbes into the circulation from 
a suppurating focus. In the former case suppuration rarely occurs ; in 
the latter instance it is always present and attended more or less by 
extensive necrosis. 

Children and young adults who have passed through an attack of any 
of the acute infectious diseases are strongly predisposed to an attack of 
acute suppurative osteomyelitis. Excluding all such influences, there is 
still left a large number of cases where osteomyelitis attacks persons 
otherwise apparently in perfect health. My own observations induce me 
to attribute to exposure to cold an important role as an exciting cause. 
I do not wish it to be understood that exposure to cold alone could ever 
result in an attack of acute suppuration of the medullary tissue. Pus- 
microbes inhabit persons in perfect health, and they do not cause disease 
as long as the circulation remains normal or as long as the tissues are not 
injured or otherwise prepared for the exercise of their pathogenic activity. 
If, however, in such persons the circulation in the medullary tissue is 
disturbed suddenly in consequence of a sudden or prolonged chilling of 
the surface of the body, congestion, mural implantation, and localization 
of floating pus-microbes occur in a locality which offers the least resist- 
ance in such an emergency, and a suppurative inflammation is established 
in the myeloid tissue. I have repeatedly observed cases of osteomyelitis 
in boys who, after active exercise, suddenly became chilled by bathing 
in cold water, or who, after an exciting game of base-ball, stretched them- 
selves out on the cold ground to rest. A disturbance of the equilibrium 
of the circulation from any cause is an important factor, in precipi- 
tating not only an attack of acute osteomyelitis, but many other local 
infective processes in persons already infected with the essential cause. 

On investigating the clinical history of cases of osteomyelitis we are 



240 DISEASES OF THE BONES. 

often able to ascertain the existence of a suppurating distal focus from 
which the pus-microbes entered the circulation, producing later the sup- 
purative inflammation in bone under the influence of one or more excit- 
ing causes. This observation should teach the profession not to make 
light of perhaps insignificant suppurative surface affections, as they may- 
become the essential cause of serious complications. 

In the relapsing form of the disease the micro-organisms have 
remained quiescent for some time, and then wake up to new activity. 
Rosenbach has claimed, and for good reasons, that the pus-microbes in 
osteomyelitis may remain in a latent condition for twenty years, when, 
under the influence of provoking influences, they reproduce the disease, 
although usually in a modified form. It is on this account that usually 
recurrence takes place in the same bone and in the same part of the 
bone. 

Symptoms. — The clinical picture of a case of acute osteomyelitis is 
almost characteristic, and, when once seen and carefully studied, can 
always be recognized. It is only in the gravest form, when the local 
symptoms are overshadowed by the general symptoms, that a careful 
observer meets with difficulties in making an early diagnosis. As an 
early diagnosis is in the interest of the patient as well as the surgeon, all 
signs and symptoms should be carefully considered to enable the physi- 
cian to make a prompt and correct diagnosis. Mistakes in diagnosis 
have often resulted in the loss of valuable time and indefinite postpone- 
ment of effective therapeutic measures so essential in limiting the exten- 
sion of the disease and in the prevention of fatal complications. 

The disease is usually ushered in by a chill and other symptoms 
indicative of the commencement of an acute suppurative affection. 
In grave cases, even during the earliest stages, the general symptoms 
are out of all proportion to the local lesion, presenting a complexus 
of symptoms typical of profound septic intoxication. I have observed a 
number of cases of multiple osteomyelitis where the patients passed into 
a typhoid condition, with muttering delirium, dry tongue, diarrhcea, and 
a continued form of fever, with a high temperature and rapid pulse, who 
died within a week, before the local disease had time to develop marked 
symptoms of its existence. In such cases the prominent general symp- 
toms are those of a malignant form of progressive sepsis. In some 
cases of acute osteomyelitis the actual development of the disease is 
preceded by premonitory symptoms which indicate the route through 
which infection has probably taken place. A premonitory bronchial 
catarrh Avould suggest the possibility that infection had occurred through 
the mucous membrane of the respiratory organs, while infection through 
the intestinal canal would give rise to diarrhoea as a preceding symptom. 
The local symptoms will be considered separately, as a correct early 
diagnosis can only be made by a careful study of these individually and 
collectively. 

Pain. — Pain is one of the earliest and most constant symptoms of 
acute osteomyelitis. It may be absent in multiple osteomyelitis, where 
the patient passes into a condition of stupor almost from the beginning. 
The pain is described by the patient as being excruciating, of a boring, 
tearing, or throbbing character. It is not strictly limited to the area 
involved by the disease, but is often diffuse, extending to the adjacent 



DIFFUSE ACUTE SUPPURATIVE OSTEOMYELITIS. 241 

joints and over a considerable portion of the shaft. In osteomyelitis of 
the upper end of the femur it is often referred to the groin and the knee- 
joint. It is of unusual severity, owing to the tension caused by the 
inflammatory product in a tissue surrounded by an unyielding case of 
compact bone. Pain increases in severity as the exudation becomes 
more abundant, and is diminished or subsides almost completely with 
the escape of the inflammatory product from the interior of the bone into 
the surrounding yielding soft tissues. Sudden diminution or cessation of 
pain is an almost certain indication that perforation of the bone has 
occurred, and that the pus has escaped into the loose paraperiof^teal 
tissues. The location of the pain should be carefully ascertained, as in 
multiple osteomyelitis this symptom will indicate, at an early time, the 
number and location of bones affected. In multiple osteomyelitis the 
disease may appear simultaneously in several bones far apart, or the 
disease appears in one bone first, and other bones are attacked later suc- 
cessively. The secondary infections are usually of a milder type, with 
a corresponding diminution in the severity of this symptom. The 
appearance of pain in a new locality is generally an indication that 
another bone has become involved. The severity of the pain in acute 
cases is often proportionate to the temperature, as it is greatly increased 
during the night, when the fever reaches the highest point. 

Tenderness. — Tenderness is a more valuable diagnostic symptom than 
spontaneous pain in the early recognition of the disease and in locating 
the primary suppurating focus. The patient is seldom able to locate 
accurately the primary starting-point of the pain in an inflamed bone, 
as the pain is diffuse, but the pain caused by pressure will enable the 
surgeon to locate the primary focus within the bone with accuracy, even 
before any external swelling has made its appearance. During the first 
few days the area of tenderness will correspond to the extent of the dis- 
ease in the interior of the bone, and the centre of this area will cor- 
respond to the primary focus of inflammation. The area of tenderness 
can be readily mapped out on the surface of the limb by digital pressure, 
and the centre of this space corresponds to the point of original infection. 
Tenderness is most acute where the disease has approached nearest the 
surface of the bone, and by this means the surgeon locates the site for 
early operation. The tenderness is caused by the secondary periostitis. 
In osteomyelitis of the long bones pain and tenderness appear first near 
one of the epiphyses, and extend later toward the shaft of the bone as 
the deep-seated inflammation and the accompanying periostitis ascend or 
descend in that direction. 

Swelling. — The absence of external swelling during the first few days 
of an attack of acute osteomyelitis has often given rise to mistalces in 
diagnosis. As the primary inflammation is located in the interior of 
a bone, external swelling is absent until the inflammation has extended 
to the surrounding soft structures, particularly the periosteum and the 
loose paraperiosteal connective tissue. With the appearance of the 
secondary periostitis swelling comes on very rapidly, which at first can 
be felt as a hard induration, soon followed by extensive subcutaneous 
oedema and deep-seated fluctuation. The rapid local dissemination of 
the process is largely due to the unyielding nature of the tissues around 
the primary focus, and to the fact that the blood-vessels are directly 
Vol. II.— 16 



242 DISEASES OF THE BONES. 

concerned in the extension of the inflammation by the coagulated con- 
tents becoming the channels for the diffusion of the septic infection, 
their contents forming a nutrient medium for the pus-microbes. 

Thrombo-phlebitis is a constant and early condition in every case of 
acute osteomyelitis. The oedema of the soft parts is caused, in part at 
least, by the deep-seated venous obstruction. The external swelling sel- 
dom appears before the end of the first week, but when it once shows 
itself it increases very rapidly. The swelling usually extends far beyond 
the limits of the affected bone, very often involving the entire limb. The 
secondary suppurative periostitis results in extensive denudation of the 
bone, a large portion of the shaft being surrounded by pus. As soon as 
the suppurative inflammation extends to the connective tissues the disease 
resembles very closely deep-seated phlegmonous inflammation ; diffiise 
burrowing of pus takes place between the bone and the periosteum and 
among the muscles. Within a few days an immense abscess or a very 
extensive purulent infiltration develops in this manner. 

Enlargement of Subcutaneous Veins. — Another evidence of deep- 
seated venous obstruction is presented by a marked enlargement of the 
subcutaneous veins. The veins are not only decidedly dilated, but, 
apparently, have approached nearer the surface of the skin. After ten- 
sion has been relieved by free incision this temporary varicosity dis- 
appears. 

Redness. — The skin over the affected bone presents a pale, normal 
appearance until the pus reaches the subcutaneous tissue, when it pre- 
sents a red or brownish-red discoloration. The inflammatory blush is 
usually circumscribed, and indicates the place where spontaneous rupture 
would occur in the absence of surgical intervention. 

Loss of Function. — A limb the seat of acute osteomyelitis is helpless. 
Suspension of function is one of the conspicuous clinical features of this 
disease. The limb is as useless as though one of the principal bones 
had been fractured. The patient is unable to raise it or to move the 
nearest joint. The limb is not only useless, but the patient will not 
permit it to be moved, and complains of a sensation as though it would 
break on its being lifted or otherwise manipulated. 

Spontaneous or Pathological Fracture. — If the entire diameter of a 
long bone is destroyed by the inflammation and the sequestrum becomes 
partially or completely separated before the involucrum is strong enough 
to provide the necessary resistance, a spontaneous fracture may occur or 
the bone will break upon the slightest application of force. This acci- 
dent does not occur frequently, but when it does happen it is readily 
recognized and indicates the extent of destruction of bone. 

Epiphyseolysis. — Separation of an epiphysis from the diaphysis in the 
epiphyseal line is of more frequent occurrence than pathological fracture 
of the shaft. It is another form of pathological fracture which occurs 
in consequence of necrosis, inflammatory osteoporosis, or molecular dis- 
integration of bone in the epiphyseal line. It is readily recognized by 
the existence of a false point of motion and the displacements which 
usually attend fractures in such a locality. Epiphyseolysis seldom occurs 
before the end of the fourth or sixth week from the beginning of the 
attack, and is always attended by involvement of the adjacent joint in 
the inflammatory process. 



DIFFUSE ACUTE SUPPURATIVE OSTEOMYELITIS. 243 

Synovitis. — Synovitis of joints situated in close proximity to osteo- 
myelitic foci is the rule. The joint affection varies according to the 
character of the inflammatory product. Catarrhal synovitis appears 
during the first few weeks, while suppurative synovitis usually occurs 
later as a complication of acute suppurative osteomyelitis. If the effusion 
into the joint is of a serous character, it occurs not as a result of infec- 
tion with pus-microbes, but in consequence of vascular disturbances out- 
side of the limits of the area of infection. The serous effusion appears 
rapidly and gives rise to pain and contraction of the joint, but, as a rule, 
•disappears spontaneously after the evacuation of the osteomyelitic 
product. 

Suppurative synovitis follows infection of a joint with the same mi- 
crobes that caused the osteomyelitis, which organisms reach the joint either 
directly through some pathological defect of the epiphysis or through 
the lymphatics or blood-vessels. It is possible also that the infection 
■of the joint in some cases is referable to the same source as the bone 
affection. The occurrence of an attack of suppurative synovitis greatly 
■aggravates the general and local symptoms — much more so than if the 
■effusion is of a non-septic character. If any doubt exists as to the 
character of the effusion, an exploratory puncture will furnish the neces- 
sary diagnostic information. 

Diagnosis. — In doubtful and obscure cases a diagnosis should be 
made by a very careful consideration of the history of the case and 
a painstaking study of the general and local symptoms. Instead of 
coming to premature and erroneous conclusions, it is advisable to reason 
by exclusion and to enter deeply into the subject of differential diagnosis. 
Mr. Holmes has well said that acute suppurative osteomyelitis is more 
frequently recognized at post-mortem examinations than at the bedside 
of the sick. It has often been mistaken and treated for such affections 
as periostitis, ostitis, inflammation of joints, rheumatism, meningitis, 
typhoid fever, erysipelas, and even phlegmonous inflammation of soft 
parts. When we remember that periostitis, ostitis, synovitis, and 
phlegmonous inflammation are constant secondary lesions, and intimately 
associated in the clinical history of every case of osteomyelitis, and, 
furthermore, that the fever attending the latter closely resembles typhoid 
fever, it is not surprising that mistakes in the early diagnosis of this 
■disease are not infrequent even in the practice of experienced surgeons. 
A careful consideration of every feature of the clinical picture presented 
by each case only can enable us to arrive at correct diagnostic conclu- 
sions. There is no single pathognomonic symptom that would infallibly 
lead us to a correct diagnosis. 

The fever in acute cases is continuous, with well-marked evening 
exacerbations, but the difference between the morning and evening 
temperatures is less marked and typical than in typhoid fever. The 
pulse is a good indication of the degree of intoxication, as well as the 
appearance of the tongue. In rapidly fatal cases the pulse is very small 
and rapid from the beginning, the tongue is dry, and the teeth are cov- 
ered with sordes. In such cases delirium of a muttering type is also 
present, and the intoxication of the nervous centres masks the local 
symptoms, rendering the diagnosis exceedingly difficult. It is always 
^advisable to make careful investigation as to an existing or antecedent 



244 DISEASES OF THE BONES 

peripheral focus of suppuration, and the possible exposure to some acute 
infectious disease. 

Differential Diagnosis. — I have already insisted that in difficult 
cases a diagnosis should be made by excluding the affections that have 
been mistaken for osteomyelitis. 

Typhoid Fever. — The acutest and most serious forms of osteomyelitis 
have been most frequently mistaken for typhoid fever. The prom- 
inence of the grave general symptoms and the absence of local signs 
are responsible for many of the mistakes in diagnosis that have been 
committed. Goltdammer has reported a typical case of this kind. The 
general symptoms simulated typhoid fever so closely that the patient, 
after an illness of ten days, was sent to the medical wards as a severe 
case of typhoid fever. The pulse ranged between 110 and 120 ; tem- 
perature, 40° to 41° C. ; tympanites, dry tongue, enlargement of spleen, 
bronchitis, rapid respiration, and delirium. On close examination a 
slight swelling was found over the lower part of the right tibia, with 
tenderness on pressure — symptoms which finally enabled the attending- 
physician to make a correct diagnosis. During the progress of the case 
pleuritis, parotitis duplex, and synovitis of the right shoulder-joint made 
their appearance. The patient died eight days after admission or 
eighteen days from the beginning of the disease. The necropsy revealed 
the existence of acute osteomyelitis of the tibia, and pyaemia. 

Many such cases have been recorded where the differential diagnosis 
between acute osteomyelitis and typhoid fever was difficult, if not impos- 
sible, until the local symptoms became more prominent. The premon- 
itory symptoms in typhoid fever are more constant and conspicuous 
than in osteomyelitis. In the latter affection the bronchial or intestinal 
catarrh which occasionally precedes the attack constitutes the only pre- 
monitory symptom, and, as a rule, the disease commences abruptly with- 
out any such warnings. A decided chill instead of repeated attacks of 
chilliness ushers in the disease. Chassaignac believes that diarrhoea is 
present in almost all cases in the beginning, but this is not in accord 
with my own observations. The location and character of the pain 
have already been described. Pain, and especially tenderness, should 
receive careful attention in the examination of the patient, and these 
symptoms must be largely relied upon in locating the disease. 

Rheumatism. — Acute rheumatism is a polyarticular disease, and the 
pain and swelling are from the first limited to the affected joints. The 
general symptoms are not as severe as in grave cases of osteomyelitis. 
The swelling of the joints comes on much earlier than in the compli- 
cating synovitis of osteomyelitis, which seldom appears before the second 
week. 

Phlegmonous Inflammation. — E. von Wahl makes the statement that 
fluctuation is at first circumscribed in phlegmonous inflammation of the 
connective tissue, while it is diffuse from the beginning in osteomyelitis. 
This distinction is a good one. The external swelling in phlegmonous 
inflammation appears much earlier than in osteomyelitis. The presence 
of fat-globules in osteomyelitic pus was regarded as diagnostic by Chas- 
saignac and Roser. Fat-globules are often found in osteomyelitic pus, 
but they are not invariably present, and may also occur in the pus of a 
phlegmonous inflammation. In osteomyelitis the superficial swelling is at 



DIFFUSE ACUTE SUPPURATIVE OSTEOMYELITIS. 245 

first cedematous, extends symmetrically around the entire bone, and 
gradually diminishes at a point where the morbid process in the interior 
of the bone has become arrested. Phlegmonous inflammation is seldom 
complicated by synovitis. 

Periostitis. — I have repeatedly called attention to the fact that sup- 
purative primary periostitis is an exceedingly rare aifection. This disease 
is enumerated here because so many surgeons still persist in calling the 
secondary periostitis following osteomyelitis a primary affection. An 
important element in the differential diagnosis between these two affec- 
tions is the absence of external swelling in osteomyelitis for the first few 
days, regardless of the severity of other symptoms ; also its rapid dif- 
fusion after it has once made its appearance. In periostitis swelling is 
one of the earliest symptoms. The functional disturbance in periostitis 
is also less marked than in osteomyelitis. 

Erysipelas. — Occasionally osteomyelitis has been mistaken for erysipe- 
las when the disease had reached the connective tissue and produced 
phlegmonous inflammation. Uncomplicated erysipelas is a dermatitis ; 
the swelling is limited to the skin, and the characteristic discoloration 
of the skin is present from the beginning, and spreads regardless of 
regional conditions which limit the extension of osteomyelitis and 
phlegmonous inflammation. 

Prognosis. — The prognosis depends largely on the virulence and 
extent of the disease. The benefits of early operative treatment must 
also enter into consideration in judging of the probable final result. 
Modern aggressive surgery has greatly diminished the mortality of acute 
osteomyelitis. Under the old expectant, non-antiseptic treatment the 
death-rate was great. Thus, Demme lost 4 out of 1 7 cases ; Luecke, 
1 1 out of 24 ; Kocher, 9 out of 26 ; and Schede, 3 out of 23 cases. 
Multiple osteomyelitis, with grave symptoms of sepsis from the begin- 
ning, almost without exception proves fatal in less than two weeks. 
Death in such cases is caused by progressive sepsis resulting from the 
entrance of large quantities of pus-microbes and their toxines into the 
circulation. If the patient escapes this, the first source of danger to 
life, he is still exposed during the duration of the acute symptoms to the 
more remote risks incident to the presence of septic thrombo-phlebitis, 
which so often becomes the direct cause of a fatal pyaemia. Another 
fatal accident which may occur is fat-embolism. The medullary tissue is 
liquefied by the suppurative inflammation, some of the free fat-globules 
are forced into the circulation by the increased intra-osseous pressure, and 
death is preceded by the usual symptoms which attend this complication. 

The clinical thermometer is an important prognostic aid in this as 
well as in many other acute infective processes. If the morning and 
evening temperature remains continuously high — that is to say, ranges 
between 40° and 40.5° C. — during the first week, it indicates a severe 
case. The more the general symptoms resemble a severe case of typhoid 
fever the graver the prognosis. The occurrence of decubitus is always 
an unfavorable sign. Necrosis of the bone to a greater or less extent is 
the rule. The extent of periosteal detachment during the acute stage is 
no indication of the area of subsequent sequestration. Joint affections 
and partial or complete separation of one or more epiphyses are frequent 
complications, and add to the danger to life and detract from the func- 



246 DISEASES OP THE BONES. 

tional result. Stiifness, ankylosis, and contracture of joints are events 
that cannot be avoided in all cases, even by the most skilful and atten- 
tive treatment. If the articular cartilages are destroyed by suppurative 
arthritis, the best result that can be hoped for is a useful but ankylosed 
joint. Pathological fractures through the shaft of a bone or epiphyse- 
olysis are complications which greatly increase the duties of the attending 
surgeon, but from which the patients frequently recover with a useful 
Hmb. 

Pathological Anatomy. — The pathology of suppurative osteomy- 
elitis consists in morbid processes which originate in the medullary 
tissue of bone, and secondarily affect the true bone tissue, the perios- 
teum, and finally the soft tissues outside of the periosteum, followed by 
regenerative processes in which the periosteum and remaining medullary 
tissue are most actively engaged if the patient survives the disease. 
Acute osteomyelitis is essentially a phlegmonous inflammation of the 
marrow of bone. This disease attacks, preferably, the long bones, 
although the scapula, clavicle, ribs, and ilium are also frequently affected, 
especially in cases of multiple osteomyelitis. Of the long bones, the 
femur is most frequently affected. In this bone the disease manifests a 
special predilection for the lower epiphyseal region, while in the tibia 
the order of frequency is reversed. As this disease, without direct ex- 
posure of the marrow, is caused by infection with pus-microbes, which 
reach the tissue through the circulation, the inflammatory process must 
commence in the capillaries from mural implantation of microbes or 
leucocytes containing them. Intense alteration of the capillary wall is 
always present, giving rise to rhexis. The pus almost always presents a 
reddish appearance, which is owing to the presence of extravasated blood. 
The inflammation rapidly extends to' the larger veins, which become 
blocked by the formation of a thrombus. If pus-microbes enter the 
thrombosed veins in sufficient quantity to cause liquefaction of the coag- 
ulated blood, pyaemia results from transportation of fragments of such 
infected thrombi to distant organs. The thrombo-phlebitis is one of the 
immediate causes of necrosis. The central medullary cavity is rapidly 
transformed into an abscess-cavity (Plate I.). The pus infiltrates the 
spongy bone tissue and occupies either the entire medullary cavity, a cer- 
tain section of it, or is in the form of multiple abscesses. The infection 
from the central focus extends along the blood-vessels, and soon reaches 
the periosteum, which becomes the seat of an inflammation which resem- 
bles pathologically the primary medullary lesion in every respect. Pus 
accumulates between the periosteum and bone, causing often very exten- 
sive, and occasionally complete, denudation of the underlying bone. At 
some points the periosteum is destroyed when the pus reaches the sur- 
rounding connective tissue, which then becomes the seat of a phlegmonous 
inflammation. The periosteal defects are not restored subsequently, and 
at these points openings, called cloacae, remain in the new bone. After 
the active symptoms have subsided the suppurative periostitis gives way 
to a process of repair, during wliich the periosteum forms a case of new 
bone around the necrosed portion, which case in technical language is 
called an involucrum (Fig. 276). The abscess in the soft parts heals, and 
one or more fistulous communications between the surface of the skin 
and the dead bone in the interior of the involucrum remain. The external 



PLATE I, 





OSTEOMYELITIS OF FEMUR, 



DIFFUSE ACUTE SUPPURATIVE OSTEOMYELITIS. 



247 



openings are often quite distant from the cloacse, and in such cases it is 
difficult, if not impossible, to discover the dead bone by probing. In 
cortical necrosis with extensive destruction of the periosteum no involu- 
crum forms, and the sequestrum is later found imbedded in the soft 
tissues in a cavity lined by granulations. The necrosed bone after its 
separation is called a sequestrum. If necrosis has occurred at different 
points, several sequestra will be included by the involucrum. Separation 
of the sequestrum, like the elimination of necrosed soft tissues, is accom- 



FiG. 276. 



Fig. 277. 




Necrosis of tibia. 



Necrosis of entire sliaft of tibia. 



plished either by suppuration or, what is more common, by granulation. 
The size of a sequestrum varies from a small spicula of bone to the whole 
shaft of a bone. Such pieces of bone always show an irregular or den- 
tated outline, which is due either to the original shape of the sequestrum 
or to the action of the granulations, which diminisih the size of the de- 
tached bone after its separation. Necrosis is said to be central if the 
sequestrum is composed of tissue from the interior of the shaft, complete 
if it represents the entire thickness of the bone, and cortical if it is com- 
posed of the external compact layer only (Fig. 277). 

In osteomyelitis after amputation, terminating in necrosis, the seques- 



248 DISEASES OF THE BONES. 

trum usually comprises the entire thickness of the sawn bone and appears 
tubular in shape (Plate II.). 

In complete necrosis a pathological fracture necessarily takes place if 
separation occur before a firm involucrum has formed. In such cases 
restoration of the continuity of the bone is effected by the involucrum. 
Fracture of the involucrum has happened occasionally during a necrotomy 
or under circumstances which led to fracture of bone. Bending of the 
involucrum is liable to occur if the patient resumes the use of the limb 
before ossification has been completed. The medullary canal in the new 
bone after central or complete necrosis is seldom restored to perfection. 
The new bone is harder and heavier than normal bone (osteosclerosis), 
but in exceptional cases it remains porous and soft (osteoporosis) — a con- 
dition described by Volkmann and Schede which may become the cause 
of various degrees of deformity from bending or infraction of the shaft. 
Separation of the sequestrum will take place in from four weeks to three 
months, according to the age of the patient and the location and extent 
of the necrosis. 

Treatment. — The prophylactic treatment of osteomyelitis consists in 
the timely treatment of peripheral accessible suppurative lesions and in 
avoidance of the usual exciting causes. As the gastro-intestinal canal is 
undoubtedly more frequently the route through which infection takes 
place than is generally supposed, and as nature's resources often attempt 
elimination of the pathogenic micro-organisms in this direction, it would 
appear rational to administer a brisk cathartic upon the appearance of 
the first symptoms, as such treatment might prove of great value in 
arresting further infection from this source. A large dose of calomel, 
followed by a saline cathartic, would meet this indication most efficiently. 
Kocher has advised the internal use of salicylate of soda, giving from 
6 to 24 grammes in divided doses during twenty-four hours. Salol, beta- 
naphthol, and the sulphites are valuable intestinal antiseptics. Opium 
must be given in sufficient doses to alleviate pain. The affected limb ■ 
should be immobilized from the beginning to prevent joint contractions, 
and suspended in a slightly elevated position. The use of the ice-bag or 
cold coil is rational, and often relieves pain. Blistering and the applica- 
tion of iodine do more harm than good. If the cold applications do not 
prove agreeable to the patient, hot antiseptic fomentations should be 
tried. In multiple osteomyelitis, with pronounced symptoms of progres- 
sive sepsis almost from the beginning of the attack, it is doubtful whether 
any surgical treatment will have any effect in preventing a fatal termina- 
tion. In such cases general infection occurs almost from the beginning, 
and at the necropsy very little, if any, pus is found in the inflamed 
medullary tissue. The indicatio vitalis in these cases calls for the use 
of stimulants. 

Early Operation. — An early operation in the treatment of acute 
osteomyelitis is one which is performed before secondary suppurative 
periostitis has appeared, hence before any appreciable swelling has taken 
place. The operative removal of the infected marrow at this stage of 
the disease will not only become the means of greatly diminishing the 
mortality of this disease, but will also prove of the utmost value in 
limiting its extension — consequently, also, in preventing extensive necro- 
sis. The early removal of the localized product of infection and throm- 



PLATE 




TUBULAR SEQUESTRA FROM AMPUTATION OF THE FEMUR, 



DIFFUSE ACUTE SUPPURATIVE OSTEOMYELITIS. 249 

bosed veins is the surest prophylactic measure against pya3mia and re-in- 
fection from tlie primary focus. The operation should be done as soon 
as a positive diagnosis can be made and under strict antiseptic precautions. 
Although operating for a suppurative affection, infection from without 
must be carefully avoided. The primary location of the disease, usually 
in the vicinity of an epiphyseal line, is accurately found by searching for 
the most tender point. This should be done before the patient is placed 
under the influence of an anaesthetic. Over this point, or as near to it 
as the nature of the soft parts will permit, an incision is made down to 
the bone. The operation should be rendered bloodless by the use of 
Esmarch's constrictor, provided there is but little cedema. After cutting 
through the skin and fascia the remaining part of the dissection should 
be made by the use of blunt instruments. When the periosteum is 
reached, it is incised and reflected with the attached soft parts. The 
bone is then opened with a small round chisel : in the further steps of 
the operation ordinary chisels, such as are used by carpenters, answer an 
excellent purpose. If no pus has formed, the osteomyelitic focus is 
recognized by the softness and great vascularity of the tissues and the 
escape of bloody serum. If pus is found, it will probably appear at 
this early stage as an infiltration. The object of the operation is not 
only to open the bone, but to remove at the same time all of the infected 
tissues. The opening in the bone is therefore enlarged in the direction 
of the shaft to the extent of the disease in its interior. If the suppura- 
tive inflammation is extensive, involving half of the bone or perhaps the 
entire shaft, it is advisable to make several incisions over the bone in 
the same line, instead of one large incision, thus avoiding a large wound 
and perhaps injury of important structures ; at the same time the interior 
of the bone is rendered accessible to direct treatment by opening the bone 
at the corresponding points from which the intervening infected medulla 
and cancellous bone can be scraped out with a sharp spoon. After the 
whole cavity has been thoroughly curetted, it is disinfected by irrigating 
with a solution of corrosive sublimate (1 : 1000), and then dried and 
mopped out with a 12 per cent, solution of chloride of zinc. Peroxide 
of hydrogen is also an excellent remedy for disinfecting the cavity. The 
cavity is then packed with iodoform gauze, which is brought out of the 
wound or wounds to serve the purposes of a capillary drain. A copious 
antiseptic dressing is then applied, and the limb immobilized in proper 
position upon a splint. If on the following day the temperature shows 
no reduction, the dressings are removed, antiseptic irrigation is again 
employed, and the limb dressed as before. If, in spite of the early 
operation and careful antiseptic after-treatment, the suppurative in- 
flammation extends to the periosteum and the connective tissue, the 
antiseptic occlusive dressing should give way to warm compresses kept 
saturated with one of the mild antiseptic solutions. Frequent irrigation 
with a 5 per cent, boric-acid solution, a saturated solution of acetate of 
aluminum, or a weak sequeous solution of iodine or bromine should be 
employed. 

Intermediate Operation. — An intermediate operation for osteomyelitis 
is one which is resorted to after the disease has reached the periosteum 
and connective tissue outside of it ; that is, after it has become compli- 
cated by phlegmonous inflammation of the soft parts. At this stage 



250 DISEASES OF THE BONES. 

multiple incisions and numerous tubular drains are required to effect 
complete evacuation and secure free drainage. At this time the affected 
bone should be opened at different points, which will enable the surgeon 
to employ intra-osseous antiseptic irrigations. Large openings in the 
bone under these circumstances might lead to pathological fractures. The 
subsequent treatment is conducted on the same principles as a case of 
phlegmonous inflammation and purulent infiltration of the soft parts. 
Catarrhal synovitis is treated by aspiration, and suppurative synovitis by 
incision, drainage, and antiseptic irrigations. 

Eemoval of necrosed bone should be postponed until the sequestrum 
has separated, and, in the case of the femur and humerus, until the invo- 
lucrum is strong enough to maintain the normal position of the limb. 
When the continuity of a bone has been destroyed either by a patho- 
logical fracture or the removal of a part or an entire diaphysis, which 
has separated before the involucrum has become sufficiently firm to serve 
the purpose of an efficient mechanical support., a suitable splint must be 
applied for a long time to guard against shortening and bending of the 
new bone. During the septic acute stage of osteomyelitis with suppu- 
rative synovitis amputation may become necessary to save the life of the 
patient. In exceptional cases the same sad alternative may become a 
necessity after the acute symptoms have subsided, for the purpose of 
removing the source of exhaustive suppurative discharges. Should 
signs of pyaemia arise, our main reliance must be placed on the admin- 
istration of large doses of quinine and alcohol. As soon as the acute 
symptoms have subsided, iron, especially tinctura ferri chloridi, should be 
freely administered. 

Late Operation (Necrotomy). — Late operations are performed for the 
purpose of removing the remote results of the inflammation — the necrosed 
bone and the granulations lining the involucrum. This operation is 
called necrotomy or sequestrotomy. It consists of the removal by ope- 
rative interference of the dead detached bone. The removal of dead 
bone by maceration with dilute mineral acids (Andrews) or by digestion 
with pepsin and other digestive agents has not yielded satisfactory re- 
sults. The operative removal of a sequestrum should always be pos1> 
poned until complete separation has taken place and the involucrum is 
strong enough to support the limb. Sequestrotomy, if properly per- 
formed, is one of the most satisfactory of all operations, as it is attended 
by little or no danger to life and is usually followed by a favorable result. 
Its performance has been greatly simplified by the use of anaesthetics 
and Esmarch's elastic constrictor. As the operation should have for its 
object not only the removal of the sequestrum, but also the rendering of 
the bone-cavity aseptic, it should be performed under strict antiseptic 
precautions. Whenever it is safe to make the incision in the line of one 
or more fistulous openings, this should be done ; but when these are in 
localities where there would be danger of wounding important vessels, 
muscles, or nerves, another location from which the bone can be reached 
safely must be chosen. In operations upon the humerus the exact loca- 
tion of the musculo-spiral nerve must be remembered, and if the incision 
necessarily comes close to this structure, the deep dissection is made slowly 
and with the use of blunt instruments until the nerve is found, when it 
can be held out of the way by the use of a blunt retractor In opera- 



DIFFUSE ACUTE SUPPURATIVE OSTEOMYELITIS. 



251 



tions upon the lower end of the femur, even if the fistulous opening 
should be in the popliteal spa(!e, the incision down to the bone should 
be made in the course of the intermuscular septum, on the outer or inner 
side, as the posterior surface of the femur can be reached from either 
side by making the incision long and by keeping close to the bone, sepa- 
rating the soft tissues well, and keeping them out of the way by the use 
of retractors. Where the bone is covered by thick layers of rnuscles the 
incision is made in the direction of the muscles and at a point corre- 
sponding to the intermuscular septum. When the bone is reached tlje 
periosteum is incised and reflected with the soft tissues attached to it 
(Fig. 279). 

The involucrum is opened by using chisels of different sizes and 
shapes, as shown in Fig. 278. In old-standing cases the involucrum is 
as dense as ivory, and the chiseling is an exceedingly slow and laborious 
process, as only small chips can be removed with each cut of the chisel. 



Fig. 278. 



Fig. 279. 



Fig. 280. 






Neuber's method of treating^ 
aseptic bone-cavities. 

The brittleness of the 
new bone should Avarn 
the surgeon to chisel 
with care, as otherwise 
a fracture might result. 
Formerly the extrac- 
tion of the sequestrum 
ended the operation ; at 
the present time the op- 
eration is made to meet 
another indication — re- 
moval of all infected 
tissue. To accomplish 
this object it is neces- 
sary to expose the inte- 
rior of the involucrum 
freely in order to enable 
the surgeon to remove 
with a sharp spoon the 
infected granulations lin- 
ing it. The bone-cavity after the completion of the operation should 
present the appearances shown in Fig. 279. The cavity is then rendered 
aseptic by irrigation with a solution of carbolic acid or corrosive subli- 
mate, when it is dried and lightly dusted with iodoform. For the pur- 
pose of securing speedy definitive healing of the wound numerous 
methods have been suggested. Neuber made flaps of the skin from 



Size and shape of cut- 
ting edge of chisels 
used in sequestrotomy. 



Cavity in tibia after removal 
of sequestrum and scraping 
out 01 granulations. 



252 



DISEASES OF THE BONES. 



Fig. 281. 



each side, which he fastened to the floor of the cavity in the manner 
shown in Fig. 280. 

It has been my experience that necrosis of the flaps is not an infre- 
quent accident after this operation. In other instances the flaps do not 
attach themselves to the bone surface, and the wound has to heal by a 
tedious process of granulation. E. Hahn made extensive undermining 
of the skin on each side for the purpose of obtaining a cutaneous cov- 
ering for the bone. This operation is open to the same objections. Bier 
has suggested osteoplastic resection of the involucrum (Fig. 281). Vari- 
ous materials have been used to fill the bone-cavity, either to remain per- 
manently or temporarily. D. J. Hamilton suggested sponge. Schede 
made use of the aseptic blood-clot. In the clinic at Bonn plaster of 
Paris has been used, and recently Sonnenburg plugged the cavity with 
an amalgam, such as is used by dentists in filling teeth. For a number 
of years I have used chips of decalcified bone in aiding the process of 
repair in such cases. Kiimmell of Germany and Duplay of France have 
extended this method of treatment, and report equally satisfactory results. 
Schede's blood-clot is not sufficiently permanent to furnish a satisfactory 
temporary framework for the granulations during the time required in 
the treating of a large bone-cavity. The bone-chips when properly pre- 
pared are not only aseptic, but antiseptic, and sufficiently durable to 
serve as a bridgework during the tedious process of 
repair. The decalcified bone is removed gradually by 
the granulations springing from the surface of the cav- 
ity and the peripheral cover, which in due time are 
transformed into permanent bone tissue. The more my 
experience increases with this method of treating aseptic 
bone-cavities the better are the results. 

Essential conditions for success are asepticity of the 
cavity and the absorbable material employed in filling 
it. The great advantages of this method of dealing with 
aseptic bone-cavities are that the external wound heals 
by primary intention, and that the bone tissue lost by 
disease and operation is replaced by new tissue. In 
ideal results the process of repair is so complete that no 
defect remains at the site of the operation, which is in- 
dicated only by a linear scar. After the cavity has been 
properly prepared, iodoformized decalcified bone-chips 
are poured into it until this is packed with them to the 
level of the periosteum. After removal of Esmarch's 
constrictor blood escapes between the bone-chips and 
coagulates at once, thus forming a desirable and useful 
cement-substance which permeates the entire packing, 
and temporarily glues, as it were, the chips together and 
Bier's osteoplastic re- the entire mass to the walls of the cavity. The perios- 
c?um." °^ ™'>">i'i- teum should be carefully preserved in exposing the bone, 
and, after implantation, is sutured over the surface of 
the bone-chips with absorbable aseptic sutures. If the bone is deeply 
located, it may become necessary to apply a second and third row of 
buried sutures to bring into accurate contact other overlying soft parts. 
The skin is finally sutured with silk or silkworm gut. In some instances 




CIRCUMSCRIBED CHRONIC SUPPURATIVE OSTEOMYELITIS 253 

it would be undoubtedly superfluous to secure any form of drainage, as, 
when the cavity is perfectly aseptic and hemorrhage is not in excess of 
requirements, healing of the entire wound would be accomplished under 
one dressing. Experience, however, has taught me that tension arising 
from extravasation of blood often exerts an injurious influence upon the 
process of healing, and should be carefully avoided. A string of large- 
sized catgut inserted into the lower angle of the wound answers an excel- 
lent purpose as a capillary drain. A copious antiseptic dressing is then 
applied, the limb immobilized, and placed for at least twelve hours in an 
elevated position. A limited suppuration is not incomjDatible with speedy 
healing of the cavity, as many of the peripheral bone-chips are replaced 
by granulations, and the remaining space can later be treated in a similar 
manner by secondary implantation of decalcified bone-chips. This, how- 
ever, should be postponed until all suppuration has ceased and the cavity 
has been rendered thoroughly aseptic by appropriate treatment. Bier 
has recently advocated osteoplastic necrotomy (Fig. 281). With saw, ham- 
mer, and chisel the accessible part of the wall of the involucrum is raised 
with the overlying soft parts in the form of a lid, the sequestrum re- 
moved, the cavity rendered aseptic, when the parts temporarily resected 
are replaced and fastened in their former relative positions with sutures. 
This method of performing necrotomy is applicable only in exceptional 
cases, and even Avhen successful the results are not better than those 
following less severe procedures, and we may therefore anticipate that its 
sphere of application will be a very limited one. 

ClECUMSCEIBED ChRONIC SUPPURATIVE OSTEOMYELITIS. 

This is the bone-abscess of Stanley and the older authors. The eti- 
ology of this form of suppurative inflammation is the same as in the 
diffuse variety, only that the primary microbic cause limits its action to 
a smaller area. Clinically, two varieties can be distinguished : 1 , primary 
epiphyseal circumscribed osteomyelitis, known as epiphysitis ; 2, second- 
ary circumscribed osteomyelitis. The first kind is occasionally met with 
as a multiple affection, and is then attended by more or less constitutional 
disturbance, and not infrequently results in epiphyseolysis. The second- 
ary form occurs in the scar-tissue of bones that have been the seat of an 
attack of diffuse suppurative osteomyelitis, the patient apparently having 
recovered completely from the primary attack years before. It is still a 
question under discussion if in these cases the infection is caused by pyo- 
genic microbes which have remained in the tissues in a quiescent state 
since the primary attack, or whether it is caused by a new infection of 
the tissues weakened by the first attack. Rosenbach is of the opinion 
that recurring attacks of osteomyelitis in the same bone are caused by 
pus-microbes which have remained in the tissues, and which again be- 
come pathogenic when the tissues around them are rendered susceptible 
to their action by subsequent causes. I am strongly inclined to the same 
opinion. I have seen numerous cases where, in persons from sixteen to 
twenty-five years of age, repeated attacks of circumscribed osteomyelitis 
occurred in a bone which during childhood had passed through an attack 
of acute osteomyelitis. In the relapsing form the disease, with few excep- 
tions, is circumscribed. This would seem to indicate that the action of 



■252 



DISEASES OF THE BONES. 



each side, which he fastened to the floor of the cavity in the manner 
shown in Fig. 280. 

It has been my experience that necrosis of the flaps is not an infre- 
quent accident after this operation. In other instances the flaps do not 
attach themselves to the bone surface, and the wound has to heal by a 
tedious process of granulation. E. Hahn made extensive undermining 
of the skin on each side for the purpose of obtaining a cutaneous cov- 
ering for the bone. This operation is open to the same objections. Bier 
has suggested osteoplastic resection of the involucrum (Fig. 281). Vari- 
ous materials have been used to fill the bone-cavity, either to remain per- 
manently or temporarily. D. J. Hamilton suggested sponge. Schede 
made use of the aseptic blood-clot. In the clinic at Bonn plaster of 
Paris has been used, and recently Sonnenburg plugged the cavity with 
an amalgam, such as is used by dentists in filling teeth. For a number 
of years I have used chips of decalcified bone in aiding the process of 
repair in such cases. Kummell of Germany and Duplay of France have 
extended this method of treatment, and report equally satisfactory results. 
Schede's blood-clot is not sufficiently permanent to furnish a satisfactory 
temporary framework for the granulations during the time required in 
the treating of a large bone-cavity. The bone-chips when properly pre- 
pared are not only aseptic, but antiseptic, and sufficiently durable to 
serve as a bridgework during the tedious process of 
repair. The decalcified bone is removed gradually by 
the granulations springing from the surface of the cav- 
ity and the peripheral cover, which in due time are 
transformed into permanent bone tissue. The more my 
experience increases with this method of treating aseptic 
bone-cavities the better are the results. 

Essential conditions for success are asepticity of the 
cavity and the absorbable material employed in filhng 
it. The great advantages of this method of dealing with 
aseptic bone-cavities are that the external wound heals 
by primary intention, and that the bone tissue lost by 
disease and operation is replaced by new tissue. In 
ideal results the process of repair is so complete that no 
defect remains at the site of the operation, M'hich is in- 
dicated only by a linear scar. After the cavity has been 
properly prepared, iodoformized decalcified bone-chips 
are poured into it until this is packed with them to the 
level of the periosteum. After removal of Esmarch's 
constrictor blood escapes between the bone-chips and 
coagulates at once, thus forming a desirable and useful 
cement-substance which permeates the entire packing, 
and temporarily glues, as it were, the chips together and 
the entire mass to the walls of the cavity. The perios- 
teum should be carefully preserved in exposing the bone, 
and, after implantation, is sutured over the surface of 
the bone-chips with absorbable aseptic sutures. If the bone is deeply 
located, it may become necessary to apply a second and third row of 
buried sutures to bring into accurate contact other overlying soft parts. 
The skin is finally sutured with silk or silkworm gut. In some instances 




Bier's osteoplastic re- 
section of involu- 
crum. 



CIRCUMSCRIBED CHRONIC SUPPURATIVE OSTEOMYELITIS 253 

it would be undoubtedly superfluous to secure any form of drainage, as, 
when the cavity is perfectly aseptic and hemorrhage is not in excess of 
requirements, healing of the entire wound would be accomplished under 
one dressing. Experience, however, has taught me that tension arising 
from extravasation of blood often exerts an injurious influence upon the 
process of healing, and should be carefully avoided. A string of large- 
sized catgut inserted into the lower angle of the wound answers an excel- 
lent purpose as a capillary drain. A copious antiseptic dressing is then 
applied, the limb immobilized, and placed for at least twelve hours in an 
elevated position. A limited suppuration is not incompatible with speedy 
healing of the cavity, as many of the peripheral bone-chips are replaced 
by granulations, and the remaining space can later be treated in a similar 
manner by secondary implantation of decalcified bone-chips. This, how- 
ever, should be postponed until all suppuration has ceased and the cavity 
has been rendered thoroughly aseptic by appropriate treatment. Bier 
has recently advocated osteoplastic necrotomy (Fig. 281). With saw, ham- 
mer, and chisel the accessible part of the wall of the involucrum is raised 
with the overlying soft parts in the form of a lid, the sequestrum re- 
moved, the cavity rendered aseptic, when the parts temporarily resected 
are replaced and fastened in their former relative positions with sutures. 
This method of performing necrotomy is applicable only in exceptional 
cases, and even when successful the results are not better than those 
following less severe procedures, and we may therefore anticipate that its 
sphere of application will be a very limited one. 

Circumscribed Chronic Suppurative Osteomyelitis. 

This is the bone-abscess of Stanley and the older authors. The eti- 
ology of this form of suppurative inflammation is the same as in the 
diffuse variety, only that the primary microbic cause limits its action to 
a smaller area. Clinically, two varieties can be distinguished : 1 , primary 
epiphyseal circumscribed osteomyelitis, known as epiphysitis ; 2, second- 
ary circumscribed osteomyelitis. The first kind is occasionally met with 
as a multiple affection, and is then attended by more or less constitutional 
disturbance, and not infrequently results in epiphyseoh^sis. The second- 
ary form occurs in the scar-tissue of bones that have been the seat of an 
attack of diffuse suppurative osteomyelitis, the patient apparently having 
recovered completely from the primary attack years before. It is still a 
question under discussion if in these cases the infection is caused by pyo- 
genic microbes which have remained in the tissues in a quiescent state 
since the primary attack, or whether it is caused by a new infection of 
the tissues weakened by the first attack. Eosenbach is of the opinion 
that recurring attacks of osteomyelitis in the same bone are caused by 
pus-microbes which have remained in the tissues, and which again be- 
come pathogenic when the tissues around them are rendererl susceptible 
to their action by subsequent causes. I am strongly inclined to the same 
opinion. I have seen numerous cases where, in persons from sixteen to 
twenty-five years of age, repeated attacks of circumscribed osteomyelitis 
occurred in a bone which during childhood had passed through an attack 
of acute osteomyelitis. In the relapsing form the disease, with few excep- 
tions, is circumscribed. This would seem to indicate that the action of 



254 DISEASES OF THE BONES. 

pus-microbes is mitigated during their sojourn in the body, or that the 
tissues around the infected area are less predisposed to diffusion of the 
infection. 

The tibia, femur, and humerus are the bones which are most fre- 
quently attacked by recurrent osteomyelitis. The secondary attacks 
occur either in the centre of the sclerosed bone, the former site of the 
infected medullary cavity, or near one of the epiphyseal lines. I have 
no doubt that secondary osteomyelitis will be of less frequent occurrence 
after early operations for osteomyelitis as antiseptic sequestrotomy will 
be more generally practised. 

Symptoms. — The local symptoms predominate over the general. 
Fever is slight or entirely absent, except in cases of multiple epiphysitis. 
The most important local symptoms are pain and tenderness. The pain 
is deep-seated, intense, of a boring or gnawing character, and is gene- 
rally more severe after exposure to cold, active exercise, and during the 
night. It is often intermittent, and has frequently been wrongly inter- 
preted as neuralgia of bone. The tenderness is circumscribed, and cor- 
responds to the location of the suppurating focus. It is due to a circum- 
scribed secondary plastic periostitis. The external swelling is slight, 
and often completely wanting. Usually neither redness nor oedema is 
present. 

Syphilitic osteomyelitis is to be distinguished from the suppurative 
variety by its attacking persons of very different physical conditions, by 
its tending to form new bone or causing necrosis, by there often being 
no suppuration induced, by its not involving neighboring articulations, 
by its frequent occurrence in cranial bones, and by the favorable result 
that usually follows proper treatment. 

Pathological Anatomy. — Limited suppurative osteomyelitis gives 
rise to a circumscribed abscess, which varies in size from that of a pea 
to that of a walnut. Necrosis seldom takes place ; if it does, the seques- 
tra are small and composed exclusively of cancellated bone. If the 
abscess is situated in an epiphysis, it may open into the adjacent joint 
and become the starting-point of a suppurative arthritis (Fig. 282). 
Thrombo-phlebitis, sepsis, and pyaemia are rare complications. The bone 
around the cavity is usually thickened and sclerosed. The periostitis 
which attends chronic suppurations in bone always assumes a plastic 
type, as the periosteum is beyond the reach of pus-microbes. Epiphys- 
eal osteomyelitis is often associated with chondritis and osteoporosis — con- 
ditions which may result in pathological fractures. If in this form of 
osteomyelitis the suppuration extends to the periosteum, a circumscribed 
suppurative periostitis occurs, which is followed by the formation of 
small abscesses in the epiphyseal region. Limited necrosis in these cases 
is of frequent occurrence. Inflammation of joints often complicates 
epiphysitis. 

Treatment. — Multiple epiphysitis should be treated by early incision 
and drainage under strict antiseptic precautions. The use of the chisel 
or trephine may become necessary to expose deep-seated foci. The 
external incision must be made in such a manner as not to endanger the 
joint. Early operative treatment is the best-known prophylactic against 
the occurrence of joint-complications and pathological fracture. In bone- 
abscesses the inflammatory focus can be located externally with accuracy 



CIBCUMSOniBED CHRONIC SUPPURATIVE OSTEOMYELITIS. 256 

by the presence of a circumscribed area of tenderness, and the centre of 
the tender spot constitutes the guide in the search for the abscess. After 
the subperiosteal exposure of the bone the chiseling is done in the direc- 
tion of the centre of the bone by making a track perhaps an inch square. 

Fig. 282. 




Circumscribed osteomyelitic abscess in lower epiphysis of femur, opening into knee-joint : lining 
membrane in upper part of cavity detacned. 



If the abscess is not found at a certain depth, the surrounding tissue is 
explored with a small drill in different directions until pus is found, 
when further excavation is again made with the chisel. As soon as the 
abscess has been fully exposed, the pus is washed out and the size of the 
cavity ascertained by probing. As the abscess is often surrounded by a 
zone of tissue infiltrated with pus, all of the infected tissues are scraped 
out thoroughly with a sharp spoon, after which it is prepared for the 
implantation of decalcified antiseptic bone-chips in the same manner as 
in operations for necrosis. These are very favorable cases for this pro- 
cedure, as the area of infection is limited and the mechanical removal 
of the infected tissues can be accomplished with a great deal of certainty. 
I have repeatedly seen cavities the size of a small orange in the head of 



256 I)Ii!EASi:s OF TIIK liOSKS. 

the tibia heal under two (Iri'ssiiiiis. with perfect reslorution of the iHuie 
destroyed hv the ditfease and removed durini;- (lie operaliitn. 

TrnKum.AU 0,srix>JiYi',i.rris. 

Etiology. — (^lironii' osteomyelitis of the cpijilivseal extremities oftlie 
hiiij;- bones and of the short, and tiie Hat bones, is iisiiaily the result 
of infection with the haeillns of tuberculosis. This view of its essential 
mierobie. cause was eutertnined by a number of leadinij' surji'cous lon^ 
before the bacillus of tuberculosis was diseoveri'd by Robert Koch in 
18S2. What was formerly described as scrofula of liouc is now gener- 
ally recognized as tubercular osteomyelitis. The modern views reji'ard- 
iuii' the ctioloi;y of this form of chronic intlaiumation of bc>nc arc based 
on accurate clinical observations, tlie results of carefuHy-coudncted 
experiments on the lower animals, baeterioloi;ii'al inxcstinalions, and 
pathological research. Tuberculosis of bone occurs either as a [iriuuiry 
or sei'ondary atl'cetiou. In the former instance we taUc it Ibr granted 
that locali/atiou of the bacillus has not taken place in any other organ 
of the body, and that the tubercular lesion in bone presents itself as an 
isolated single atrection. In the second case the bone alVection occurs as 
a secondary iui'cction from some antecedent tubercular (bens. I am 
ineliueil to believe that primary infection of bone is an (wcecdingly rai'c 
affection, and Konig has arrived at the same conclusion on the basis of 
an enormous clinical experience. 'I'lie frequency with which pidmonarv 
tuberculosis is met with in cases of bone tuberculosis, and the tiict that 
the lymphatic glands and the thoracic duct are also I'reqncutly the scat 
of tuberculosis, speak in tiivor of this assumption. The tubercular 
lesions which give rise to metastatic tuberculosis may be very nunute, 
and elude detection even on making a careful examination on the post- 
mortem table. Buhl's assertion that in tubercular alTcelions of dillercnt 
organs without an appreciable old tuluM'cnlar focus this was not absent, 
but overlooked, may yet receive corroboration by <'arei'ul research in the 
future. Schlenker speaks of the frccpicncy with which latent tuberculo- 
sis is found at nein-opsics where non-tubercular alTcctions have caused 
death. Out of 01 eases without active or manil'est tnbei'culosis he found 
that post-mortem (>xaniination revealed the |)rcscn(^e of latent tuberculo- 
sis in 27 ; that is, in 4-1 jtcr cent, of the total cases. lie believes that 
if the examination had been carried liii'thcrby the use of the niicrosco|)e, 
the number would have been still greater. The clinical history often 
points to some anteeedeut chroni(^ all'ection of a tubercular nature. In 
such leases the history is very often something as follows: A patient has 
])assed through an attack of jdeuritis, during which he has ])erliaps 
cxpe(^torated blood, but aft(>r a while apparent reeoxcry Ibllows, but the 
patient has lost^ llcsh and does not gain in weight ; at the sanu^ tinu' the 
appetites is imjiaired. Frequently more (U* less cough remains ; a slight 
trauma is followed by chronic osteomyelitis, which in its course (Vc- 
qucntly involves the adjacent joint. Ivescetion "is pcM'Ibrmed. liocal 
recurrence takes phu^e, necessitating hnally an amputation, and the 
pa.tient rec^overs from the operation, but dies of i>ulmonary taibereulosis 
in the course oi' -a lew years. This gloomy aspect of bone tuberculosis 
rests on an extensive (finical experience of surgeons wiio are (H'r'lainly 



TUBEJRCULAR OSTEOMYELITIS. 257 

inclined to regard, if possible, the bone affection as a local disease. The 
patient, and often the medical attendant, usually attribute to trauma an 
important r6le in the causation of bone-and-joint tuberculosis. The 
trauma, however, must be regarded at best in the light only of an 
exciting cause, as no amount of injury can produce the affection without 
the presence of the essential cause — the microbe of tuberculosis. The 
trauma only serves as an exciting cause in the production of bone tuber- 
culosis in persons already infected with the bacillus of tuberculosis. The 
clinical fact remains that bone tuberculosis can be traced only in a small 
percentage of the cases to a traumatic origin. It is, as Volkmann 
asserted long ago, characteristic that the injury preceding the develop- 
ment of the disease is always slight, often quite insignificant : tubercu- 
losis of bone, even in tubercular subjects, seldom if ever follows a frac- 
ture, as the injury in such cases is productive of such active cell-pro- 
liferation that it will hold in abeyance the pathogenic action of the 
bacilli which might reach the seat of injury with the extra vasated blood. 
In 293 cases of tuberculosis of bone studied by Watson Cheyne, in 188 
no definite cause was assigned, while in 105, or 38.8 per cent, of the 
whole number, the trouble was directly ascribed to the injury. 

Tubercular disease of bone is more frequent in males than females, 
particularly after the first decade, which would indicate that traumatism 
must be regarded as an exciting cause in a certain percentage of cases. 
Like suppurative osteomyelitis, tubercular osteomyelitis attacks most 
frequently young persons and that part of the bones predisposed to the 
localization of pathogenic microbes, the epiphyseal region of the long 
bones. 

Heredity is an important factor in the causation of bone tuberculosis, 
as well as of tuberculosis of other organs. Tuberculosis of the bones in the 
new-born has never been found, but it is well known that it can appear 
within a few months after birth, and the conditions under which this 
occurs are familiar. Besides direct transmission of the disease from 
parents to child, a certain vulnerability of the tissues of congenital origin 
must be recognized as an indirect cause. In children so predisposed the 
clinical history often reveals obstinate eczema, blepharitis, ciliaris, glan- 
dular enlargements, and other infantile affections of unquestionable 
tubercular nature preceding the bone affection. Surgeons are well aware 
of the fact that the existence of an hereditary tendency to tuberculosis 
adds greatly to the gravity of the disease. The course is usually more 
rapid, spontaneous cure less likely, and the prospects of a favorable 
result after operative treatment less favorable than in the acquired form 
of tuberculosis. 

The diseases incident to infancy and childhood, such as pertussis, 
measles, scarlatina, and diarrhoea, frequently furnish the necessary con- 
ditions for the development of osteotuberculosis. In the adult the 
attack is often preceded by one of the acute infectious diseases, such as 
typhoid fever, pneumonia, and pleuritis. Pregnancy and lactation are 
also important etiological factors. 

Ssmaptoms and Diagnosis. — The general symptoms are often no 
indication of the existence or extent of the local disease, as patients with 
quite extensive bone tuberculosis may present every indication of unim- 
paired health, and a small osseous focus may produce a rapidly^fatal 
Vol. II— 17 



268 DISEASES OF THE BONES. 

miliary tuberculosis. In all cases of suspected bone tuberculosis a care- 
ful examination should be made of every organ, in order to discover the 
primary tubercular d6p6t or existing complications. Uncomplicated 
tuberculosis of bone is essentially a chronic process, and the general 
symptoms furnish but little information in reference to its inflammatory 
character. Febrile reaction is slight or entirely absent. A slight rise 
of temperature toward evening or during the night is very suggestive. 
Progressive anaemia is always an unfavorable symptom in all forms of 
so-called local tuberculosis, as it indicates either the presence of additional 
foci in important organs or accompanies the exhaustive purulent dis- 
charges after secondary infection with pus-microbes. The occurrence of 
mixed infection, with or without a direct infection-atrium, is usually 
announced by a high temperature and other symptoms of septic infection. 
Emaciation is present when the disease is far advanced and complicated 
by abscesses, or when a more important organ is similarly affected. 

In incipient cases the local symptoms should be studied with the 
utmost care, individually and collectively. 

Pain. — Pain is an almost constant symptom, but its intensity is 
subject to great variation. Tension, the most important factor in the 
production of pain, is a much less marked feature in tubercular than 
suppurative osteomyelitis. Children suffering from spina ventosa com- 
plain of little or no pain, although a whole phalanx of a finger may 
be almost completely destroyed by a central tubercular osteomyelitis. 
In rib tuberculosis the pain is either entirely absent or slight. In tuber- 
culosis of the neck of the femur it is often referred to the knee. It is 
aggravated when the disease invades an adjacent joint. In primary 
synovial tuberculosis a sudden aggravation of this symptom announces 
the extension of the disease to the bones. This symptom is promptly 
relieved in a case of tubercular spondylitis by suspension and fixation, 
and rest in the recumbent position, and greatly exaggerated by flexion 
of the spinal column, which inflicts increased pressure upon the bodies 
of the inflamed vertebrae. The pain is of a dull, aching character, and 
is intermittent, and more severe during the night. The nocturnal ex- 
acerbation of the pain, as evidenced in children by restlessness during 
sleep, moaning, grinding of teeth, and horrible dreams, is often one of 
the first symptoms which excite suspicion of the existence of osteo- 
tuberculosis. 

Tenderness. — While tenderness is an important symptom in detecting 
and locating suppurative osteomyelitic foci, it is of far greater value as 
a diagnostic aid in the recognition of osteotuberculosis in its earliest 
stages. It is caused by a circumscribed periostitis over the tubercular 
lesion. The existence of an area of tenderness near a joint, correspond- 
ing to a tubercular focus in the interior of a bone, is one of the surest 
indications of the existence of tubercular osteomyelitis. In many cases 
of epiphyseal tuberculosis patients have been treated for some supposed 
joint lesion simply because this symptom was not carefully searched for, 
or, if discovered, its significance was misinterpreted. The existence of 
a limited area of tenderness in the epiphyseal line and the absence of 
joint lesions will enable the surgeon to locate accurately a focus in the 
interior of the bone. In the examination of tubercular joints it is im- 
portant to search for this symptom over both articular extremities for 



TUBERCULAR OSTEOMYELITIS. 259 

the purpose of detecting osseous foci — a matter of great importance, not 
only from a diagnostic, but also from a therapeutic, point of view. 

Swelling. — Mr. Lawrence and, later, Samuel Cooper showed by dem- 
onstration of numerous specimens of tubercular joints that the spindle- 
shaped enlargement is not caused by expansion of the articular extrem- 
ities, as was formerly supposed, but by swelling of the soft tissues around 
the joint. With the exception of diffuse tubercular osteomyelitis of the 
shaft of the long bones swelling is usually absent or slight in osteotu- 
berculosis. External swelling is absent until the atrophic layer of 
compact bone yields to the intra-osseous pressure — as may be seen in 
advanced cases of spina ventosa — or until, by pressure-atrophy over 
the centre of the focus, the compact layer is perforated and a soft, cir- 
cumscribed, boggy swelling forms underneath the periosteum. The 
tubercular periostitis which now eusues soon reaches the paraperiosteal 
tissues, when the swelling increases more rapidly, and is followed by the 
formation of a tubercular abscess. Such abscesses are prone to migrate 
in the same manner as tubercular abscess of an articular origin. CEdema 
is usually not well marked, even if the abscess is large, unless secondary 
infection with pyogenic microbes has occurred. 

Redness. — The skin over a tubercular abscess presents an abnormally 
pallid appearance until this structure has been reached by the tubercular 
process, when it becomes red or livid. This discoloration precedes the 
spontaneous rupture of the abscess underneath it. 

Atrophy of Limb. — Atrophy of limb is a constant feature of bone 
and joint tuberculosis. It is progressive, and appears in a few weeks, 
certainly in a few months, after the beginning of the attack. It has 
been attributed to various sources — viz. inactivity, neuritis, vasomotor 
changes, and reflex influences. It is in all probability the direct result 
of prolonged non-use of the limb and reflex influences. It affects not 
only the bone, but every tissue of the limb. Atrophy of the muscles 
constitutes the most important part of this complication. 

Differential Diaonosis. — With few exceptions a chronic inflam- 
mation in the epiphyseal extremities of the long bones or in the body of 
a vertebra is of a tubercular character. In doubtful cases certain diag- 
nostic measures should be resorted to in order to enable the surgeon to 
make a differential diagnosis. 

Akido-peirastik. — Exploration of a doubtful swelling with a short 
steel needle was introduced by Middeldorpf for the purpose of ascer- 
taining the consistence and probable structure of the tissue composing 
the swelling. This is an exceedingly valuable diagnostic aid, and, if 
properly performed, devoid of danger. The puncture is made in the 
centre of the tender area, and in a direction corresponding to the prob- 
able location of the central focus. If the needle meet with any consid- 
erable resistance in the bone, it is advanced by rotary movements : the 
arrival of its point in the granulating centre or caseous focus is an- 
nounced by a sudden loss of resistance. By advancing the needle suf- 
ficiently to touch with the point the oj^posite side of the cavity its 
probable size and exact location can be ascertained. 

Inoculation Experiments. — In cases of great doubt little fragments 
of granulation tissue or a few drops of the liquefied material can be 
removed from the inflamed area with an exploring syringe, and with 



260 DISEASES OF THE BONES. 

the material removed a guinea-pig or rabbit can be inoculated. If it is 
a case of tuberculosis, the disease will be reproduced in the animal. 
The result of the experiment thus furnishes the final proof of the nature 
of the affection. 

Probing. — This diagnostic resource should not be employed indis- 
criminately in the exploration of fistulous tracts, as the careless use of 
the probe has resulted in a great deal of harm by causing infection with 
pus-microbes and by aggravating the tubercular lesion. . The danger 
attending the use of this instrument can be greatly diminished by a 
recourse to adequate antiseptic precautions. Cauterization of the granu- 
lating surface with nitrate of silver previously to or simultaneously with 
the use of the probe, by coating it with the melted salt, is another 
efficient prophylactic measure. The affections which are liable to be 
mistaken for tubercular osteomyelitis, and lice versd, are — synovial 
tuberculosis, sarcoma, echinococcus, epiphyseal multiple osteomyelitis, 
chronic osteomyelitis, and syphilitic affections of bone. A careful 
study of the clinical characteristics of these affections, combined with 
a careful consideration of the signs and symptoms present, will enable 
the practitioner to arrive at correct diagnostic conclusions. In cases 
of doubt in the differential diagnosis between tubercular osteomyelitis 
and syphilitic bone affections, in which the results of treatment do not 
furnish positive diagnostic information, it may become necessary to resort 
to inoculation experiments in making a final diagnosis. 

Prognosis. — Spontaneous healing of a tubercular focus in bone is 
possible under favorable conditions. If the patient is well nourished, 
and, above all, if the blood is in a normal condition, limitation of the 
disease may occur before caseation has taken place, and if cheesy material 
has formed and can be removed by operative interference, the prospects 
of a permanent recovery are good. It must be, however, admitted that 
every person who has suffered from an attack of osteotuberculosis during 
childhood or youth, even if an apparent perfect cure has been effected 
spontaneously or by operative measures, is always in danger of becoming 
the subject of re-infection from the primary or osseous focus at any sub- 
sequent time. Healing by cicatrization frequently takes place in the 
small, dry granulating foci so long as the coagulation necrosis is limited 
and no caseation has occurred. If caseation has taken place, and the 
cheesy material has not undergone liquefaction, encapsulation of the 
tubercular product can take place by the wall of granulation tissue 
lining the cavity becoming converted into cicatricial tissue, forming a 
capsule, which, for the time being at least, mechanically prevents the 
local extension of the disease. Small sequestra may become imbedded 
in a connective-tissue capsule in a similar manner. A large sequestrum 
cannot be similarly disposed of, but must be eliminated either sponta- 
neously or removed by operation before healing can be accomplished. 
If the disease invades the adjacent joint, the prognosis is more grave, 
and the chances of a spontaneous recovery are much lessened. 

The prognosis is always more serious, other things being equal, if 
the bone affected is so located that elimination of the tubercular product 
is rendered difficult, and the removal of the primary focus by operative 
treatment is anatomically impossible. The danger to life is increased if 
a large tubercular abscess has become infected with pus-microbes, as the 



TUBERCULAR OSTEOMYELITIS. 261 

secondary infection results in destruction of the granulation tissue lining 
the cavity — a condition which favors the local and general extension of 
the tubercular infection, and at the same time brings sepsis, exhaustion 
from profuse suppuration, and amyloid degeneration of important internal 
organs as additional elements of danger. 

The prognosis is always more unfavorable in persons advanced in 
years than in children, as limitation of the disease occurs more fre- 
quently in the latter. Re-infection from an osseous focus is of frequent 
occurrence, leading to pulmonary or some other form of visceral tuber- 
culosis or general diffuse miliary tuberculosis. Secondary glandular 
tuberculosis is of rare occurrence. 

The duration of the disease is an important element from a prognostic 
view. Multiplicity of the affection augments the danger to life and 
retards a spontaneous cure. Konig has observed miliary tuberculosis 
following primary osteotuberculosis only sixteen times out of thousands 
of cases that have come under his personal notice. In all of these cases 
the general tuberculosis followed operations for tubercular lesions. Dif- 
fuse miliary tuberculosis may and does occur without such an exciting 
cause. I have observed tubercular meningitis develop in young children 
on several occasions in the course of tubercular coxitis without operative 
intervention, which shows that a tubercular focus in bone, iindisturbed 
by operation, may become the distributing-point of bacilli, and constitute 
the immediate cause of metastatic tuberculosis in another organ, or general 
miliary tuberculosis. 

Treatment. — Early effective treatment is of paramount importance, 
because the intrinsic tendency of the disease is toward progressive exten- 
sion, and if left to itself sooner or later the appearance of serious compli- 
cations is the rule, spontaneous recovery the exception. 

The general treatment must be tonic and supporting. Dietetic and 
hygienic measures are of more importance and value than the adminis- 
tration of drugs. Sea-bathing and change of climate will often accom- 
plish more than bitter tonics, iron, quinine, arsenic, and cod-liver oil. A 
combination of potassic iodide with the syrup of iodide of iron has, in 
my experience, produced better results than any other method of medi- 
cation. Guaiacol is another valuable remedy, but in order to render it 
effective its use must be continued for six months to a year. I usually 
administer it in milk before meals and at bedtime in doses of four to five 
drops for an adult. If it disturbs digestion, the dose should be diminished 
or its use temporarily discontinued. Children suffering from osteotuber- 
culosis should be carefully dressed ; flannel under-garments must be worn 
constantly, except during the hot summer months, when their place can 
be taken by silk or cotton under-clothing. Sudden chilling of the sur- 
face is always detrimental, and should be carefully guarded against. 
Out-door air and a certain amount of exercise should be procured when- 
ever the local disease does not furnish a positive contraindication. Tepid 
salt-water baths are of great value in such cases, as they stimulate the 
peripheral circulation, and in so doing prevent internal congestion. An 
intelligent general treatment should go hand in hand with the use of 
appropriate local measures : it is only by such combined treatment that 
a favorable impression is made upon the disease. 

A few of the more important local agencies will now be discussed. 



262 



DISEASES OF THE BONES. 



Rest. — The importance of enforced and absolute rest cannot be over- 
estimated. Hilton, Chiene, and others have brought this important ele- 
ment of treatment forcibly to the attention of the profession. In securing 
rest for the diseased part as nearly as can be done by position and the 
use of mechanical measures, the process of repair is favored and further 
extension of the disease arrested or limited. The most efficient way to 
procure rest, not only for the affected part, but for the entire body, is to 
confine the patient to bed ; but, as these affections are noted for their 
chronicity, lasting for months and years, enforced rest by this method 
would seriously impair the general health, and the benefit derived from 
it for the local lesion would be more than overbalanced by the lack of 
fresh air and out-door exercise ; and on this account it is advisable, in 
the majority of cases, to resort to one of the numerous mechanical appli- 
ances which will immobilize the part, while at the same time the patient 
can avail himself of the benefits to be gained by out-door air and change 
of scenery and surroundings. In tubercular spondylitis suspension upon 
a Rauchfuss sling, with or without head-extension, and later fixation of 
the spine in extension in Sayre's plaster-of-Paris jacket, will meet this 
indication to perfection. In tuberculosis of the epiphyseal extremities 
of the long bones immobilization of the limb in a circular plaster-of-Paris 
dressing will not only secure the most perfect degree of rest, but will at 
the same time prevent contractures and partial or complete pathological 
dislocation of the articular extremities. Rest should be continued until 



Fig. 283. 





la 


m 


=" 




' 


CD 




"^ 


(T) 


ru 


" _ 


1 J 1 1 1 1 1 1 1 1 . 


'M-± 


-*- 




-- 


2_ 




:;_r ; 








:_z^ 



s^ 




Senn's exploring and injecting syringe. 

all active symptoms disappear. Rest, like all other valuable therapeutic 
agents, if continued too long will prove harmful ; hence the indications 
for its abandonment should be thoroughly and frequently searched for 
from time to time. 

Parenchymatous Injections. — The direct application of well-known 



TUBERCULAR OSTEOMYELITIS. 263 

antibacillary agents to the diseased infected tissues constitutes an import- 
ant part of the treatment. The instrument to be employed for this 
purpose is an ordinary Pravaz syringe with an asbestos piston. The 
instrument is to be sterilized by boiling before using it. I have recently 
devised a syringe for making intra-articular and parenchymatous injec- 
tions, which is shown in Fig. 283, and which I now use exclusively for 
this purpose. The remedies which have proved most successful are a 
10 per cent, emulsion of iodoform in glycerin, an emulsion of balsam 
of Peru of the same strength, and a 1 per cent, solution of tri- 
chloride of iodine. The bone is perforated with the largest needle 
of the syringe in the centre of the tender area, and after the focus 
has been reached the injection is made very slowly, in order to 
bring the emulsion or solution in contact with as large an area of 
infected tissue as possible. The injection is to be repeated every 
week or two. 

Ignipunoture. — This therapeutic resource in the treatment of bone- 
and-joint tuberculosis was introduced by Richet in 1870. The operation 
is now performed exclusively with the needle-point of a Paquelin 
cautery heated to a white heat. The site of puncture, corresponding 
to the centre of the tender area, is rendered aseptic in the usual way. 
As soon as the surface of the bone is reached the point is advanced by 
rotatory movements. The instrument is withdrawn from time to time, 
and heated before reinserting it to prevent impaction in the canal. The 
entrance of the point into the focus is announced by a sudden loss or 
diminution of resistance. If the focus is large, punctures can be made 
in different directions through the same external opening. The channel 
thus made is dusted with iodoform and an antiseptic dressing applied. 
The first effect of the operation is diminution or cessation of pain. In 
the course of two or three weeks the tubular eschar is removed and the 
canal filled with granulations. The cauterization of a deep-seated tuber- 
cular focus in such a manner destroys a part of the tubercular product 
and stimulates the surrounding tissues to an increased tissue-prolifera- 
tions : it becomes the direct means of substituting for the tubercular osteo- 
myelitis a plastic osteomyelitis. From my own experience I regard this 
procedure as a potent agent in the treatment of accessible foci of uncom- 
plicated bone tuberculosis. It is most useful in the early treatment of 
tarsal, carpal, and epiphyseal tuberculosis. 

Operative Removal of Tubercular Foci. — The operative removal of a 
tubercular focus in the epiphyseal extremity of a long bone with chisel 
and sharp spoon must be regarded as a curative and prophylactic opera- 
tion. It is intended to effect mechanical removal of the tubercular 
product, which in itself will prevent invasion of the adjacent joint. 
As such foci are usually near a joint, great care must be exercised not 
to open the joint. The external incision must be carefully planned, and 
the bone exposed by reflecting the periosteum. After the focus has been 
fully exposed with the chisel, the tubercular product and surrounding 
osteoporotic bone are removed with a sharp spoon. After thorough 
cleansing and iodoformization of the cavity, the latter is filled by decal- 
cified iodoformized bone-chips in the manner previously described. The 
periosteum is sutured separately, and over it the parts are approximated 
in the usual manner. Capillary drainage with a bundle of catgut is 



264 DISEASES OF THE BONES. 

usually indicated. An antiseptic dressing and a fixation splint complete 
the operation. 

Resection. — Resection may become necessary after the osseous focus 
has reached the adjacent joint. The operation should consist of a thor- 
ough extirpation of the diseased synovial membrane and capsule and the 
removal of the osseous focus. Typical resection should be avoided if 
possible. Surgeons limit the operative procedure more and more to the 
removal of diseased tissue, in place of typical resection. 

Amputation. — A mutilating operation is often the only choice in the 
treatment of diffuse tubercular osteomyelitis, as it offers the only chance 
for complete eradication of the disease and protection of the patient 
against general infection. It is contraindicated in the other forms of 
osteotuberculosis, unless complicated by tuberculosis of an adjacent 
joint, and even in such instances it should be limited to cases that have 
passed beyond the reach of a typical or an atypical resection. 



ORTHOPAEDIC SURGERY. 

By V. P. GIBNEY. 



General Considerations. 

Orthopedic Surgery is that branch of general surgery which has 
to do with the prevention and correction of deformity. Its intimate 
association with mechanical appliances has rather limited its scope to the 
correction of deformity by such appliances, but the orthopaedic surgeons 
of the present day have taken a more liberal view of the subject, and 
have felt it incumbent upon themselves not only to correct, but to pre- 
vent, deformity as well. The mode of correcting has been left largely 
to the individual surgeon, and for this reason operative as well as 
mechanical surgery has become a prominent feature. The practice of 
any branch of medicine or surgery presupposes a more or less intimate 
knowledge of diseases and their various manifestations ; hence it is idle 
to talk of any one method of correcting to the exclusion of others. 

When one considers the nature of deformity in general, and the mode 
of production, it is difficult to come to any other conclusion than this : 
that the orthopsedic surgeon of to-day must be conversant with the 
nature of diseases which produce deformity, of the conditions which 
predispose to deformity, must himself be a good diagnostician, must 
have familiarized himself with the clinical history of disease, and must 
know what those conditions are which predispose to or lead to deform- 
ity. For example : the various diseases in and about a joint, whether 
involving the bone or the soft parts, must be carefully considered and 
be duly recognized. 

The term orthopcedic itself is well known to mean " to teach or edu- 
cate straight." It is poor surgery to wait until distortions ensue before 
any eifort is made in the direction of prevention. 

Again, the deformities that result from various changes in utero, 
from accidents and injuries of various kinds, naturally come within the 
scope of this specialty. It is true that many deformities are not in- 
cluded within the scope of orthopsedic surgery, such as hare-lip, cleft 
palate, strabismus, flexions of the uterus, etc., for the reason that such 
deformities, as a rule, have always been managed successfully by the 
general surgeon, the oculist, or the gynsecologist, and require no spe- 
cially devised mechanical appliances to complete the cure. The day is 
passed when this specialty must rely on surgery for material assistance. 

It is proposed in this article to consider the deformities of the head 
and neck, of the spinal column, of the upper extremities, and of the 
lower extremities, irrespective of the causes producing the same. To be 
a little more explicit : Torticollis ; ostitis of the vertebrae, of the shoulder, 
the elbow, the wrist, the hip, the knee, and the ankle ; periarticular 

265 



266 ORTHOPJEDIO SURGERY. 

lesions of these joints ; rotary lateral curvature ; the deformities which 
result from paralysis and from rickets ; and club-foot in all its forms, — 
will be considered. 

Nomenclature, Etiology, and Pathology. — The deformities may 
be divided into congenital and acquired. 

The congenital deformities include the larger proportion of club- 
foot, a smaller proportion of wry-neck, many deformities of the hands, 
arrest of development of the glenoid cavity and the acetabulum, arrest 
of development of the limb, and constriction of the limb, producing 
distortions. 

The acquired deformities include such as depend upon bone or joint 
disease, periarticular diseases, traumatism, the various muscular asym- 
metries depending upon paralysis, whether cerebral, spinal, or periph- 
eral, and many of the lesions of the nervous system and the distortions 
of rickets. 

In the list of congenital deformities we have club-foot, divided into 
the following : talipes equinus, equino-varus, calcaneus, valgus and 
cavus, congenital dislocations of the shoulder and hip, and many cases 
of infantile spastic paralysis. 

It is among the list of acquired deformities that the nomenclature has 
been so confusing. With the knowledge now possessed of the pathology 
of the larger number of bone and joint diseases, we are enabled to dis- 
card many of the older names with which we have become familiar, and 
apply terms more in keeping with the true nature of the lesion. For 
instance : we speak now quite freely of tubercular ostitis, of tubercular 
arthritis, of traumatic arthritis. We have learned that tubercular lesions 
are found in the epiphyses of the long bones, and that the deformities 
which ensue are exceedingly difficult to manage and are often incurable. 
If we know, therefore, that what formerly was an obscure affection about 
the hip or knee is really a tubercular lesion of the epiphysis or the bones 
entering into these joints, and apply terms which will at once indicate 
the nature of the disease, we naturally feel that a nomenclature on such 
a basis is far preferable. 

Take the spinal column, for example. In place of the term " Pott's 
disease," or angular curvature, the term tubercular ostitis of the spine is 
of much more value, in that it enables us at once to forestall any deform- 
ity, provided we are sufficiently conversant with the nature of the dis- 
ease. The same is true of the hip, and the knee, and the ankle. The 
term " hip disease " itself is sufficiently distinctive to one who has made 
himself familiar with all the diseases about the hip, but the term " tuber- 
cular ostitis of the hip," or simply "ostitis of the hip," is at once recog- 
nized as being the best term we can apply. Take the knee also : " white 
swelling" and "chronic synovitis" are not so significant as the term 
"tubercular ostitis of the knee." 

While it is true that a certain number of excellent practitioners have 
as yet failed to accept the teachings of Koch, yet the great majority of 
surgeons, the world over, have long since adopted the earlier teachings 
of this great human benefactor. Synonyms will be given when the 
deformities of individual joints are considered. 

The pathology which concerns this article is simple enough, and may 
be easily disposed of. 



GENERAL CONSIDERATIONS. 267 

In the congenital deformities we know really very littk of the path- 
ology. The whole range of heredity is still under discussion. Able 
minds are as yet undetei'mined as to what part really heredity does play. 
Maternal impressions are really so intangible that we must dismiss them 
in considering any scientific subject. Mechanical obstructions are brought 
about in utero in various ways and at various stages of foetal develop- 
ment. The study of embryology has thus enabled us to determine in a 
theoretical way the pathogeny of club-foot. 

Without committing myself to any special theory, I may state that 
the theory which seems the most plausible is that of retarded rotation, 
propounded first by Essericht, and more fully developed by Berg of 
New York. It is assumed that the feet in early utero-gestation are in 
the position of equino-varus. It is further assumed that in the process 
of normal rotation mechanical obstruction is offered. This obstruction 
may depend upon the mother or the child, upon the nervous system or 
the circulatory system. The obstruction may be in the shape of mus- 
cular spasm at a time when a certain stage of rotation is present, or it 
may be in the shape of bands or certain dispositions of amniotic fluid 
within the uterus. If the obstruction persists long enough, the develop- 
ment of the foetus will proceed without corresponding progress in rota- 
tion. An impediment thus having been established, the feet fail to 
unfold, and at birth we have the characteristic distortion, the degree 
depending upon the amount of obstruction and the period of foetal life 
when such obstruction occurred. 

Why an arrest of development of the acetabulum should take place 
we are unable to undei'stand. The causes underlying this deformity are 
the same apparently as those which underlie cleft palate, hare-lip, and 
other similar deformities. 

In discussing the pathology of acquired deformities the bacillus of 
tuberculosis is the all-important factor to be considered. If a simple 
cellulitis about a joint occurs, the deformity is, as a rule, evanescent. 
On the subsidence of this cellulitis the distortion disappears. Deformi- 
ties which follow an irritable spine or certain neuroses in connection 
with the spine are much more persistent, yet clearly depend upon mus- 
cular spasm induced by such neurosis, and a diagnosis by exclusion 
usually suffices to make clear the pathology of such a distortion. 

The presence of pus within the sheath of muscles, pus which comes 
from foci remote from the deformity in question, explains readily the 
condition which presents. 

Fractures of bones in the neighborhood of joints, separation of epiph- 
yses, and severe contusions in general produce a kind of deformity 
which is understood when the diagnosis is fully established. 

While it is not always clear how the bacillus enters the system in an 
individual case, it is readily understood in this stage of medical science 
how the bacillus behaves in an epiphysis. Without any argument, 
therefore, we may assume that the bacillus has lodged in one or more 
centres of development on one or the other side of the epiphyseal line. 
We know the cancellous structure of the bone in this locality ; its close 
resemblance to lung-tissue has often been suggested. An inflammatory 
focus is thus established, which focus increases in area, involving first a 
practically harmless area in the neighborhood of the joint, but as it 



268 obthopjEdic surgery. 

increases, frequently under the influence of trauma, we find involvement 
of contiguous tissues, such as the articular cartilage, the periosteum, the 
synovial membrane, the cellular tissue about the joint, and ultimately 
the muscular and cutaneous structures. 

Let us take for example a case of ostitis of the hip and follow it 
through its different stages. We shall find symptoms corresponding 
very closely with the progress of the bone-lesion itself. The small focus 
or small foci, no larger than the head of a pin, give rise to obscure pains, 
to disability, and certain reflex muscular spasms. These make the little 
patient's gait unsteady, and, as a result, falls and injuries occur which 
would otherwise be avoided. The above signs may have been so 
obscure as to have escaped the attention of the parent, and have not 
come conspicuously into prominence until after one or two falls. In 
this way the fall is regarded as a cause of the disease, and the state- 
ment of the parent is regarded as evidence conclusive that the fall is the 
cause. This valuable point in the etiology has been so often elicited that 
I deem it unnecessary to dwell longer upon the subject. As this focus 
of disease increases, often under the influence of the trauma above men- 
tioned, a larger area is produced, which involves a loss of structure and 
serves also as a receptacle for the inflammatory products. In other 
words, a small abscess is formed under the influence of still further 
trauma, to which is added the trauma of walking and the trauma of 
muscular spasm. It is possible for the disease to advance thus far with- 
out appreciable deformity, but the rule is flexion of the hip and ab- or 
adduction, dependent not only on muscular action, but on an inflamma- 
tion of the ligamentous structures immediately surrounding the hip, such 
inflammation producing contracture. It is easy for one to appreciate 
how walking on a diseased femoral neck will produce bending of this 
neck, thus altering its relationship with the shaft. The undue promi- 
nence of the trochanter major is thus explained. With the occurrence 
of exacerbations we have enlarged inflammatory areas, encroaching upon 
the joint proper and producing in the joint an increased amount of 
synovial fluid. This increase of fluid must find room, and flexion of 
the joint must occur. On the subsidence of the inflammation — or on 
its recession, probably better expressed — we have subsidence of symp- 
toms and diminution of deformity. Finally, this small collection of pus 
must find its way into the joint more frequently, less frequently into 
the surrounding structures, and we have abscess. We have, then, the 
symptoms and signs of disease in the third stage. 

The same processes which have been outlined are found in the spinal 
column, in the knee, the ankle, and bones involving other joints. The 
old theory, then, of trauma as the cause of bone and joint disease, in 
children at least, ought to be abandoned. While one by diligent search 
may find individual cases which would seem to depend upon trauma, the 
rule is just the reverse. It cannot be too strongly impressed, both upon 
the surgeon and upon the layman, that there is great danger to a joint 
consequent upon falls and injuries of various kinds after the disease has 
appeared. With a knowledge of the pathology of the present day there 
is no occasion for the hideous deformities resulting from the trauma of 
accident, the trauma of muscular spasm, and the trauma of locomotion. 



TUBERCULAR OSTITIS OF THE SPINE. 269 

Tubercular Ostitis of the Spine (Pott's Disease). 

It is difficult for one who has been spared this affliction to properly 
appreciate the ravages and the distortions which tubercular disease of the 
vertebrae produces. The synonyms are : Pott's disease of the spine ; 
Caries of the spine ; Angular curvature of the spine ; Spondylitis ; Spon- 
dylarthrocace ; Tuberculosis of the spine ; Vertebral ostitis ; and Tuber- 
cular ostitis of the spine. 

The disease itself is characterized by fixation of that part of the 
column where the lesion is most active, an angular projection of the 
spinous processes in this neighborhood, a stooping posture, an interfer- 
ence with respiration, and an arrest of growth. These, in brief, may be 
regarded as the significant features of a case. 

Etiology. — The predisposing causes of tubercular disease of the ver- 
tebrae are heredity, cachexia, and age. By cachexia is understood a con- 
dition formerly known as the strumous habit, now recognized as a mild 
grade of infection, dependent upon the presence of the tubercle bacillus 
or the elements of this bacillus. This cachexia may depend remotely 
upon hereditary influences, but more particularly is induced by impaired 
nutrition occurring in the wake of some one of the exanthemata. The 
exanthemata here include whooping cough, measles, scarlet fever, cholera 
infantum, and the developmental diseases generally. Nutrition is im- 
paired in this way, especially if there be a long, tardy convalescence 
from any of these diseases. By age is meant the period between the 
second year of life and the tenth. The disease rarely, if ever, develops 
prior to the second year of life, and seldom develops after the tenth 
year. In adult life it is usually traced to trauma of some kind. 

Clinical History. — In presenting the salient points in connection 
with the development of this disease it is well to bear in mind the 
anatomy of the column and its relations with the different portions of 
the trunk. The column itself is composed, as is well known, of twelve 
vertebrae, a vertebra consisting of a body, transverse processes, articular 
facets, spinous processes, a central canal, and grooves through which the 
nerves emerge from the spinal cord. The vertebrae themselves are held 
together by strong fibrous structures. These structures are reinforced 
by the articulation of the ribs throughout the cervical and dorsal region 
and the pelvic bones in the sacral. The furrows or grooves above men- 
tioned form foramina of exit for the nerves. Again, certain muscles are 
attached to the periosteum in certain localities, and spasm of these mus- 
cles produces distortion of the column or distortion of the lower limbs 
under the influence of disease. 

The Cervical Region. — In the cervical region we have a deform- 
ity of the head and neck which is in the nature of opisthotonos, not to 
the degree of the opisthotonos which accompanies cerebro-spinal menin- 
gitis, but in reality very much like this deformity. Another deformity 
depending upon disease in this locality is flexion of the head fonvard, 
with a disposition to rest the chin on the sternum. There is Seldom that 
rotation of the head which is so characteristic of the ordinary torticollis 
with which all are familiar. The head is held backward and to the side 
a little — is carried carefully as the patient walks. The hand is fre- 
quently placed under the chin for sujoport, occasionally against the occi- 



270 



ORTHOPEDIC SURGERY. 



put or the mastoid processes. In the face there is an expression of care 
and anxiety, which becomes a distinguishing feature in the early stage 
of cervical ostitis. The shoulders are held carefully, and the body itself 
is regarded with varying degrees of care, the degree depending upon the 
special vertebrae involved. There is usually a good deal of pain in the 
course of the occipital nerves, in the upper thoracic nerves, and occasion- 
ally in branches of the brachial plexus. There is a short respiration, an 

Fig. 284. 




Exaggerated deformity in cervical Pott's. 

increase of pain Avhenever concussion or jar occurs — a disposition on the 
part of the little sufferer to avoid any such accidents. Traction on the 
head, carefully made, frequently gives relief, and in making an examina- 
tion this test becomes important in diagnosis. 

It is seldom one finds much deformity in the shape of a bosse where 
the cervical region is alone involved, but Fig. 284 represents an enor- 
mous deformity, which is very rare, and is presented in order to accen- 
tuate the changes which do take place in this region. 

The Dorsal Region. — If the disease involves vertebra belowthe first 
or second dorsal, there are very few head-symptoms. The patient presents 
the same degree of care in walking, holds" the column rigidly erect, takes 
short steps,_ grunts a good deal, has pain in the region of the stomach, known 
as gastralgia ; resists any movements to bend the column. For instance : 
if he desires to pick up anything from the floor, he stoops with the hips 
and not with the back. In recovering himself from this stooping pos- 
ture the hands are often placed upon the thighs, and he climbs up, so to 
speak, on his thighs. At night the sleep is disturbed by moan's and 



TUBERCULAR OSTITIS OF THE SPINE. 



271 



sharp cries occasionally, but the sharp cries must not be confounded 
with the shrieks of disease when it involves the hip-joint. Another 
symptom which is quite prominent is a disposition of the child to lie on 
its face or stomach across one's lap, and to avoid any play or romping 
which produces concussion. Where the disease is confined to the upper 
dorsal, and involves likewise the lower cervical, we have a deformity 




Extreme lordosis with ribs overlapping. 



known as pigeon-breast. There appears in time a deformity of the 
spinous processes known as angular curvature or kyphosis. This de- 
formity in the upper dorsal, and mid-dorsal even, is much more con- 
spicuous than the deformity in the cervical region. With the occurrence 
of the spinal deformity this thoracic deformity becomes more pro- 
nounced. As the kyphosis increases the ribs themselves participate in 
the distortion and approach by degrees the pelvis, so that in the ad- 
vanced stages it is not uncommon that the free ribs overlap the iliac 
crests. An excellent illustration of the overlapping of the iliac crests 
by the free ribs is shown in Fig. 285. One can note also the lordosis 
in this advanced case. 

When one considers the immense amount of cicatrization which must 
ensue upon tubercular inflammation of several bodies of the vertebrae, it is 
easy to understand how dwarfed a person may become, how restricted the 
thoracic cavity, how distorted the various organs in this cavity as well 
as the abdominal cavity, and how hopeless any brilliant relief to such a 
distortion. The shoulders naturally are raised, the head depressed be- 
tween the shoulders, and the general contour of the whole trunk and head 
is one that cannot be mistaken. It is well to bear in mind that a certain 



272 



OBTHOPMDia SURGERY. 



Fig. 286. 



amount of lateral curvature accompanies the progress of Pott's disease m 
this region, as well as in the cervical and lumbar regions. Some writers 

make a good deal of the lateral devia- 
tion in the early stages, and seem to 
think that this is an important sign. 
While I have myself noted occasional 
cases of this kind for the past twenty- 
four years, I do not attach to it that 
importance which these gentlemen 
think it deserves. 

This lateral deviation is well shown 
in Fig. 286, which was under the 
writer's care for two or three years. 
Curiously enough, a sister of this boy 
had a similar deformity from Pott's 
disease. 

It must not be forgotten that the 
disease as it appears in any one of the 
regions under consideration follows 
the usual course of bone disease in 
general — namely, exacerbations fol- 
lowed by long remissions, the exacer- 
bations themselves induced generally 
by trauma. 

The Lumbar Region. — It is dif- 
ficult to dissociate disease in the dor- 
sal from disease in the lumbar region, 
especially where the foci may involve 
both regions. Indeed, the foci may be confined altogether to the 
dorsal, and yet the compensating deformity may include the lumbar, 
and OTce versA. The general signs in the lumbar region are about the 
same as those in the dorsal and the cervical — namely, stiffness, pain, the 
avoidance of concussion, etc. etc. The gait, however, is peculiar, and is 
suggestive often of disease in the neighborhood of the hip-joint. The 
patient favors one limb, and even before any abscess appears there may 
be contraction of the psoas and iliacus groups of muscles on one or the 
other side, and we have flexion of the thigh with inability to com- 
pletely extend. The signs are usually obscure ; that is, we find much 
disability, much impairment of motion, sometimes long before any ky- 
phosis appears. The vertebrse are bound so intimately with the pelvis 
that it is unusual to get a high degree of deformity in the lumbar region. 
The pains are referred to the sacral plexus of nerves and are usually 
symmetrical. 

Variations and Complications. — The symptoms above outlined be- 
long to the classical cases. Any symptomatology would be incomplete 
without a reference to the odd cases and to the complications which so 
frequently arise. 

The variations in the clinical features of Pott's disease are found in 
the different regions pretty uniformly, and depend largely upon the 
mildness or severity of the initial lesion. There may, for instance, be 
groups of symptoms that are so slight and of such brief duration that 




TUBERCULAR OSTITIS OF THE SPINE. 273 

one is thrown oif his guard in recognizing the malady. These slighter 
symptoms are followed by a long period of quiescence in which the 
patient does not complain of anything. If one suspects the existence of 
disease, a personal inspection will often reveal a little irregularity of the 
spinous processes, with impairment of function of this portion of the 
column. This quiescent period may vary, therefore, from a few weeks 
to a year. In the cervical region a peculiar attitude of the head, with 
some enlargement of the cervical glands, may be all that can be recog- 
nized. In the dorsal region there may be a slight antero-posterior cur- 
vature of the spine, resembling very much the deformity of rickets. 
There may be a persistent lateral curvature, and the importance of 
this sign will depend much upon the age of the patient. 

The symptoms above recorded refer more especially to the disease as 
it occurs in children and young people. In adults we have spinal ten- 
derness the rule, while in children it is the exception. There are excep- 
tional cases where the progress is very rapid and where the symptoms 
are very acute. This branch of the subject will be dealt with more 
fully in discussing the diagnosis. Even in children there may be almost 
an entire absence of pain throughout the course of the disease. 

The complications are muscular deformities, impairment of the res- 
piratory and cardiac functions, abscess, paralysis, tubercular meningitis, 
and amyloid degeneration. 

The muscular deformities may exist in the neck, in the ilio-costal 
spaces, and in the lower limbs. The head, from lack of support, may be- 
come distorted, and the position, long maintained, induces muscular short- 
ening, so that occasionally one finds a wry-neck which is clearly a compli- 
cation of the cervico-dorsal Pott's. The muscles attached to the upper 
part of the shoulder may become shortened in the same way, and a 
peculiar shrugging of the shoulders may persist indefinitely and resist 
all kinds of treatment. Illustrations are given of these deformities 
in Figs. 284 and 286. 

The ilio-costal space usually escapes any muscular deformity, but in 
rare instances we have shortening of the muscles on one or the other 
side, and a peculiar deformity results. This is shown in Fig. 285. 

A very common deformity about the hip is due to shortening or spasm 
of the psoas and iliacus muscles, whether abscess is present or not. It 
must be remembered that these muscles take their origin indirectly from 
the bodies of the last dorsal and first lumbar vertebrae, and that spasm is 
easily induced when disease involves these vertebrae or even vertebrse 
contiguous thereto. The gait thus produced is similar to that in what 
is known as hip disease, and may range from a very slight defect to a 
hideous deformity. Deformity of this kind is shown in Fig. 287. 
Depending upon muscular deformities in the psoas and iliacus are de- 
formities of the hamstring muscles, and it is not inappropriate to speak 
of these as complications of Pott's disease. 

The respiratory and cardiac disturbances not infrequently arise from 
involvement of the nerves as they emerge from the cervical and dorsal 
vertebrae, also from the bone-deformity. The alterations in the chest- 
walls induced by the dorsal disease necessarily interfere with the action 
of the lungs, and we have short breathing, difficult breathing, and other 
symptoms of like nature. 

Vol. II.— 18 



274 



ORTHOPEDIC SURGERY. 



The disturbances that result from the presence of abscess are legion, 

and it is difficult to enumerate all 
Fig. 287. the complications that may depend 

upon the abscess complication alone. 
In the cervical region we have the 
abscess presenting on one or the 
other side of the neck, usually in- 
volving the glands and often re- 

FiG, 288. 





Psoas contracture. 



Cervical abscess. 



garded as glandular enlargement (Fig. 288). When pus escapes from 
the cervical vertebrae or the last cervical and first dorsal, its usual site is 
in the cervical triangle. When it fails to find this mode of exit, it is im- 
prisoned back of the pharyngeal wall, and we have post-pharyngeal 
abscess, which presents at times most distressing symptoms. In the 
dorsal region abscess may be imprisoned in the cavity of the bosse and 
press upon the pleura and lung, or it may burrow along the anterior 
surfaces of the ribs, and press in this way upon lung-tissue. Physical 
diagnosticians not infrequently have found evidences of pulmonary con- 
solidation on one or the other side of the column. A careful diagnos- 
tician, however, is able to recognize the distinction between compression 
of the lung and inflammatory consolidation. The abscess coming from 
dorsal vertebrae does not always behave in this way. It finds its exit 
between the ribs and presents as a tumor on the chest-walls posteriorly, 
or it may extend down the anterior surface of the column and present in 



TUBEBCULAB OSTITIS OF THE SPINE. 



275 



the lumbar region (Fig. 289). It rarely presents in the anterior portion of 
the thorax, and, while such cases have been mentioned, I fail to recall a 
single instance where a spinal abscess has appeared in this locality. It 
may be seen in almost any portion of the posterior walls of the thorax 



Fig. 289. 



Fig. 290. 





Lumbar abscess. 



Psoas abscess. 



from the neck to the lumbar region. Abscess coming from lumbar or 
sacral vertebrae appears in the sheath of the psoas muscle, in the groin, in the 
sacral region, in the ischio-rectal region, and in Scarpa's space (Pig. 290). 
It occasionally is seen in the post-femoral region, and may appear as far 
down as the popliteal space. 

The pain and distressing symptoms which are usually regarded as 
symptomatic of abscess exist in the early stage ; that is, when the pus is 
seeking an exit from the caseous mass in immediate contact with the 
vertebrae. After the escape of the pus these acute symptoms are no 
longer present, and it is well to remember that the tumor itself is not 
accompanied by pain or anything more than mechanical annoyance. 
The laity have an impression that all abscesses are painful and accom- 



276 ORTHOPEDIC SURGERY. 

panied by most distressing symptoms, while the surgeon has learned to 
distinguish between hot and cold abscess. If the contents of the sac 
become in any way infected, then the skin and tissues covering the sac 
become red, indurated, and exceedingly painful to the touch. With these 
symptoms we have marked constitutional disturbance, such as restless- 
ness, loss of appetite, marked febrile reaction. 

Complications which are the direct result of the abscess are ulcers and 
sinuses. These the more frequently follow spontaneous opening of an 
abscess, although they may, and often do, follow the most careful at- 
tempts at aseptic surgical procedures. The sinus itself may persist for 
a few weeks or many years. It is difficult to lay down any rule for the 
duration of a sinus. After it has existed for two or three years it be- 
comes a safety-valve, and its temporary closure is followed by signs of 
sepsis which make the patient very uncomfortable. Relief follows as 
soon as the drainage is re-established. Abscess may open into the phar- 
ynx, into the pleura, into the lung, into the abdominal cavity, into the 
intestine, into the vagina, into the rectum, and into the bladder. 

A not unusual complication is paralysis from compression-myelitis. 
The percentage is about fifteen. It occurs more frequently — indeed, 
almost exclusively — in those cases where the cervical and cervico-dorsal 
regions are involved. Pathologically, it is a pachymeningitis externa 
developed from a caseous ostitis of the bodies of the vertebrae. With 
this pachymeningitis we have sometimes an interstitial myelitis. The 
deformity is not necessary to the production of a compression-myelitis. 
The symptoms are a feeling of fatigue in the limbs, a dragging of the 
feet, stumbling, and a certain degree of spasm. The spasm is a later 
symptom, and when fully developed we have a very marked exaltation 
of the reflexes. There is seldom any impairment of sensation, although 
delicate tests serve to bring out more frequent impairment of sensa- 
tions than is generally supposed. The bladder is more frequently 
affected than the rectum. In advanced cases cystitis may result. The 
duration of the attack may be a few weeks or it may extend over many 
years. The average duration is about eight months. This complication 
is generally self-limited, though treatment has a great deal to do with 
hastening the recovery. Death, when it does occur, is from progressive 
myelitis. 

The treatment should be directed to the spinal column, and adequate 
protection should be given throughout the entire course of the complica- 
tion. Counter-irritation is useful, but not by any means a specific. The 
writer believes that large doses of potassium iodide will cure the greater 
number of cases. The mode of administration is to begin with small 
doses in mineral water of some kind, and increase rather rapidly up to 
from fifty to a hundred grains three times a day. The potash is well 
borne in such cases, and certainly yields admirable results. 

Tubercular meningitis is a complication of all tuberculous bone 
lesions, and does not occur any more frequently in the course of Pott's 
disease than it does in disease involving the larger joints. Meningitis 
may appear at any stage of the disease, and is not more common in one 
than in the other. My own experience leads me to state that about 8 or 
10 per cent, of all tuberculous lesions of the bones develop, sooner or 
later, tubercular meningitis. 



TUBERCULAR OSTITIS OF THE SPINE. 



277 



Amyloid degeneration, Avhile not, strictly speaking, a complication 
of Pott's disease, is more particularly dependent 
upon prolonged suppuration, which is itself a ^"^'- ^^^■ 

complication of the vertebral disease. The course 
of amyloid disease is as follows : First, the ca- 
chexia of prolonged suppuration, pain and dis- 
tress varying in degrees of intensity in the hepatic 
region, a low specific gravity of urine, enlarge- 
ment of the liver, albumin and hyaline casts in 
the urine, oedema of the face and extremities ; 
finally, general anarsarca. Fig. 291 well repre- 
sents the gross appearances of a patient before 
the advanced stages of amyloid degeneration. 

Diagnosis. — It is impossible to over-esti- 
mate the importance of diagnosis, not only in 
tuberculosis of the spine itself, but in all of the 
so-called joint diseases of childhood. The nature 
of the disease is so well known, and the means 
of relief so satisfactory in competent hands, that 
an early diagnosis may be regarded as the most 
important step in the management of the disease. 
Fortunately, we are enabled to recognize tuber- 
culous foci in bones long before any deformity 
appears. It is nevertheless true that a large 
number of cases come to treatment after the ap- 
pearance of the deformity. This is due not so 
much to the ignorance of the surgeon or the 
physician under whose observation the patient 
first comes, as it is to lack of careful examination, 
to a slovenly mode of examining patients, and to 
the utter neglect of any routine method of ex- 
amining. The best routine method to adopt is 
the examination of the patient in a state of 
nudity, an inspection of the column itself, and 
a test of the functions of the column. This, of course, presupposes a 
knowledge of the normal functions of the column and a patient inquiry 
into the symptoms. 

The history naturally comes first in the course of the examination. 
One can readily learn the behavior of the patient at home, whether the 
disposition has been to protect the spine against trauma ; the locality of 
the pains ; the presence or absence of pains in the course of certain 
nerves ; the reference of such pains to individual nerves ; the interpreta- 
tion of such pains ; the character of the sleep, whether it is disturbed or 
not by groans or cries ; the attitude the patient assumes during the day — 
for instance, whether he prefers to lie prone on the floor or on a table or 
across the mother's lap for relief of certain slight paroxysms ; whether he 
cries when lifted by the arms or by the body ; whether he walks cau- 
tiously and steps cautiously. When the evidence is all in, a careful 
summing up of the salient features, a grouping of symptoms and signs, 
will enable one to make a diagnosis and locate the lesion beyond any 
reasonable doubt. 




Amyloid degeneration. 



278 ORTHOPEDIC SUROERY. 

One must remember that the disease itself is chronic in nature — that 
there is no sudden invasion, no chill or very acute symptom, but that 
there is a gradation of symptoms from insignificant ones to those of greater 
magnitude. 

In the different regions we have — 

1. Cervical. — The position of the head; the reflex spasm of the neck- 
muscles ; the pains in the course of the occipital nerves ; an elevation 
of the shoulders ; an unnatural rigidity of the column itself, with often 
lateral deviation in the dorsal or dorso-lumbar ; pain on concussion ; 
occasionally a uniform enlargement in the posl^pharyngeal wall, which 
can be made out by the use of the finger, and occasionally tenderness in 
this locality. The signs gained by the finger in the pharynx, however,, 
are not of much value unless associated with those above named. 

2. Dorsal. — Gastralgia, pain on concussion, a moderate rigidity of the 
column, a grunting respiration, and a disinclination to bend forward. 
For instance, when one requires a patient to pick an object from the floor, 
in place of bending forward naturally to pick up the object, he assumes 
slowly a squatting attitude, puts the hand out to the side, and completes 
the act, making a peculiar grimace of the face at the same time. 

3. Lumbar. — An unusually erect attitude, associated with a certain de- 
gree of lordosis ; an inequality of step, dependent upon a little deformity 
of one or the other hip ; slight pain on concussion ; pains in the course 
of the sciatic or anterior crural nerves ; and, on closer inspection, a real 
lordosis. This latter sign has long been regarded as due to an increase 
in the thickness of the vertebrae depending upon hypersemia, and a 
swelling (?) of the intervertebral disks. 

The mode of testing the functions of the column, whether the disease 
is suspected in the dorsal or the lumbar, or both, is to place the patient 
prone on a table, and, with one hand resting across the back, move the 
hips and thighs with the other hand. All the functions of the column 
can be tested in this way, and the presence or absence of reflex spasm can 
be noted. In the lumbar region . especially it is important to test the 
functions of the hips, using hyper-extension. Reflex spasm can be 
recognized very early in the course of the disease, and is fortunately 
confined to one or the other side, not existing in both at the same 
time. 

_ It will be noted that nothing has been said about pressure along the 
spinous processes as a means of diagnosis. I have purposely avoided 
this, because so many surgeons rely upon this as an important means of 
recognizing disease in the bodies of the vertebrae. It should be borne in 
mind that the disease is not in the spinous processes — is not, except in 
rare instances, in the lateral masses — but is always in the bodies of the 
vertebrae, and that pressure upon the spinous processes so remote from 
the site of disease will not cause pain. An exception may be made in 
the case of adults. There is tenderness on pressure over the lateral 
masses and spinous processes in vertebral disease as it affects the adult. 
It is not easy to explain this difference, yet the fact is as stated. 

Diagnosis becomes comparatively easy in the stage of deformity, yet 
it is necessary to distinguish between the deformity of rickets and 'that 
of bone disease. The kyphosis of rickets is a uniform posterior curva- 
ture involving an entire region, usually the dorsal, frequently the dorsal 



TUBERCULAR OSTITIS OF THE SPINE. 279. 

and lumbar combined. There is no sharp angular projection in the 
rachitic kyphosis. In the kyphosis of Pott's disease one spinous process 
usually stands out prominently, and the neighboring ones project to a 
smaller degree, so that we have an angular deformity rather than a curve. 
In the rachitic kyphosis hyper-extension of the column either causes com- 
plete recession of the deformity or a marked diminution of the same. In 
the kyphosis of Pott's disease there is no recession of the bosse, but the 
compensating curves above and below may be overcome. In the ky- 
phosis of rickets there is a certain degree of flexibility always present. 
In that of Pott's disease there is no flexibility of the column in the region 
involved. 

Among the diseases from which to distinguish are rachitic kyphosis, 
already mentioned, malignant disease of the vertebrse, perinephritis, dis- 
ease in and about the hip, lumbago, the various spinal neuroses, cervical 
pachymeningitis, and spondylitis, whether rheumatic or traumatic. 

Malignant disease of the vertebrse is usually not marked by any de- 
formity, or, at least, the angular deformity of Pott's. There is decided 
tenderness, excruciating pain in the course of nerves, extreme tenderness 
on handling or moving the patient about, and a history usually of malig- 
nant disease in other parts of the body. Naturally, the female sex pre- 
sents the larger number of cases of malignant disease of the vertebrse, 
and it is easy usually to find the history of a breast-tumor. In Pott's dis- 
ease there is not that prolonged suffering without remissions which is so 
common to malignant disease of the vertebrse. The usual course of 
exacerbations and remissions is an important element in differential 
diagnosis. In malignant disease the severity of the pain seems incon- 
sistent with the amount of disease in the back. There ai-e various 
disturbances of the genitals, various neuroses of the lower limbs ; the 
skin is hypersesthetic, and, while there may be remissions, they are not 
complete, and exacerbations recur on slight provocation. Where any 
reasonable doubt exists efficient treatment for Pott's disease may be em- 
ployed, and failure to give relief makes the case still more suspicious and 
enables one soon to arrive at a diagnosis. Again, the cancerous cachexia 
may be present. This is so often absent in aggravated cases that it is 
not very reliable as a diagnostic feature, because in aggravated cases of 
Pott's disease there is also a cachexia which it is difficult to distinguish 
from the cachexia of malignant disease. 

A number of years ago I had quite a run of cases of perinephritis in 
hospital practice, but of recent years they have not been so common ; yet 
occasionally one finds a perinephritis presenting unusual fulness of the 
dorso-lumbar spine, with the lateral deviation which is regarded as im- 
portant as a means of diagnosis, and it is difficult then to distinguish 
this acute inflammatory lesion of the soft parts around the kidney from 
Pott's disease. The points in differential diagnosis are the following : 
Acuteness of invasion ; persistence of febrile disturbance ; early deformity 
of the hip or back, say within two or three weeks from the first symp- 
tom ; the resistance to extension of the hip ; the presence of a tumor, or 
at least marked dulness, in the ilio-costal space, encroaching at times on 
the column itself and producing a lateral deviation in the opposite direc- 
tion. None of the above signs really belong to Pott's disease. 

The diseases in and about the hip which present at times features in 



280 OBTHOPJEDIG SUBGEBT. 

common with those of Pott's disease are sacro-iliac disease, which is 
exceedingly rare, a periarthritis of the hip, ostitis of the hip, perityphlitis, 
in rare instances appendicitis. In sacro-iliac disease the spinal column 
moves quite easily under manipulation ; there is no deformity of the ver- 
tebrse ; the tenderness is in the neighborhood of the sacro-iliac junc- 
tion ; the gait is peculiar — that is, a kind of spraddling walk. In peri- 
arthritis there is absence really of spinal symptoms and presence of an 
infiltration around the hip, which is tender to pressure, which is of brief 
duration, and which is accompanied by more constitutional disturbance 
than one gets in Pott's disease. It is only necessary to mention the 
other lesions of the hip, as a careful examination will always enable one 
to make a differential diagnosis between ostitis of spine and ostitis of 
hip. In exceptional cases the abscess from the hip may have burrowed 
up into the gluteal region and have relieved the more acute symptoms, 
but the presence of the abscess itself prevents a careful comparative 
examination of the hip. It is more common to find men erring in diag- 
nosis of hip disease where the abscess comes from the vertebrae and 
extends down the gluteal region or into Scarpa's space, thus interfering 
with the proper examination of the hip. 

Lumbago affects adults as a rule, rarely affects children, comes on 
rather suddenly and after exposure to cold or a strain of some kind, is 
unattended with deformity and many of the symptoms and signs belong- 
ing to Pott's disease. A lumbago resulting from an old sprain is some- 
times very difficult to differentiate from Pott's disease, and requires a 
very close examination with the employment of all the tests. 

The neuroses of the spine may be summed up for practical purposes 
in one term — irritable spine or spinal irritation. We find this affection 
in women, and it is sufficiently marked by a variety of symptoms, such 
as tenderness over bony prominences, the sternum, the shoulders, several 
points along the spinal column ; is rarely marked by tenderness on con- 
cussion ; is usually without deformity ; and occurs, as a rule, in neurotic 
subjects. In all cases, as a rule, the spinal column is normally flexible. 

Pachymeningitis is exceedingly rare, occurs in the cervical region, 
produces many of the signs of Pott's disease, but its course differs mate- 
rially in the involvement of the nerves of the upper extremities. Many 
years have elapsed now since I have encountered a typical case of pachy- 
meningitis, yet there is an occasional report of one in literature. The 
deformity of the head is that of flexion, rather than opisthotonos or 
variations of opisthotonos. 

Spondylitis is a term employed by neurologists to represent a group 
of symptoms which really belong to irritable spine, but which seem to 
have some distinct cause, such as a periostitis of the transverse processes 
or spinous processes — a periostitis which interferes with the nerves at the 
foramina of exit, and which is either traumatic or rheumatic. Spondy- 
litis is seen most frequently at the various baths in Europe, and has been 
written up long before the term was employed by American surgeons as a 
suitable one for Pott's disease. 

Treatment. — The principles of treatment which have been recog- 
nized as paramount are — immobilization of the column, protection against 
trauma extending over a long period of time, good hygienic surround- 
ings, and constitutional measures. In order to appreciate the force of 



TUBERCULAR OSTITIS OF TEE SPINE. 281 

the principle of immobilization or fixation one must be able to make a 
diagnosis before the stage of deformity, and to look upon a case of Pott's 
disease as one of " broken back." To successfully treat a case one must 
be a good diagnostician, and one can be a good diagnostician if a routine 
method of making examinations is always observed. One must have a 
due appreciation of the clinical history, and then the term " broken back " 
is not so inappropriate after all. If one is called upon to treat a broken 
arm or a broken leg, he naturally resorts to the best means of fixing the 
broken limb in the best possible position, and of retaining this fixation 
until repair shall have taken place.. Now, in Pott's disease, instead of 
an immediate solution of continuity of the osseous structures, we have a 
gradual solution of continuity, dependent upon the progress of the tuber- 
cular process, and deformity must occur as a result of this solution of 
continuity. Fix the spine, then, before any such disastrous result, main- 
taining the fixation, under all circumstances, over a sufficiently long 
period of time for repair to take place. It must be remembered that 
destruction of the bone results from, first, the tubercular process ; second, 
the pressure of contiguous healthy vertebrae falling one against the other 
and maintained in this abnormal position by muscular spasm, a shorten- 
ing of fibrous structures, etc. etc. 

In the cervical and cervico-dorsal regions the indications are to relieve 
the diseased vertebrae from the weight of the head. This can be done, 
not so much by traction in the upward direction, as by a combination 
of traction and tilting backward of the head, so that the weight will be 
transferred from the bodies to the transverse processes. Another indi- 
cation is to overcome the muscular spasm of the anterior thoracic mus- 
cles, which act chiefly upon the shoulders. The authorities differ in their 
views as to the vertebra in the dorsal region above which the head sup- 
port is necessary. Some believe that the head should be supported when 
the disease is as low as the eleventh or twelfth dorsal, while others again 
maintain that disease below the sixth or seventh does not require any 
such support. My own views coincide with those who hold the latter 
opinion. 

The period of this fixation and protection must not be lost sight of. 
One should remember that the disease itself extends over a period of 
from three to five years, and that to ensure the best results treatment 
should be continued not only during this period, but a supplementary 
supporting treatment should continue in cases where the dorsal and 
dorso-lumbar regions are involved, in order to prevent what are known 
as compensating deformities. Ordinarily, from two to three years is long 
enough for continuous fixation of the column. By continuous fixation is 
not meant a support which cannot be removed, and is not removed, from 
time to time, for purposes of cleanliness, but removal of such apparatus 
must be made under certain precautions — precautions which ensure a 
maintenance of the good position. 

By good hygiene is meant good living, regularity in diet, and all 
those conditions of climate which serve best to check the ravages of 
tuberculosis. If, for instance, a patient can afford changes of climate, 
then the mechanical treatment should be such as will enable him to get 
the benefit of such changes. 

By constitutional treatment is understood nutrients, tonics when the 



282 ORTHOPJEDIC SVBGERY. 

health is beiow par, and all other means for building up a system whichi 
must, of necessity, be impaired. 

Unfortunately, all cases are not diagnosticated early, and treatment is 
not begun before deformity and complications appear. The principles 
of treatment, however are the same. The deformity itself calls for the 
same amount of protection against increase ; complications demand often 
surgical interference, and at times it is best not to interfere surgically. 
The management of a case, therefore, demands mechanical, constitutional, 
and surgical measures of relief. 

After a very close study of the different methods of treatment, I am 
convinced that plaster of Paris offers to the general practitioner the best, 
agent with which to construct support for the spinal column. The 
numerous objections offered are really trifling when one considers the 
immense advantages. Good plaster of Paris can be obtained in any part 
of the country ; the smooth or cross-barred crinoline is easily secured. 
I am willing to admit the necessary skill in applying plaster is not always 
at hand. Still, one can learn how to apply plaster if ordinary intelligence 
and application be employed. The process has become very simple. It 
is no longer necessary to completely suspend the patient. The dinner- 
pad is seldom employed. The details of a jacket or corset made of plas- 
ter are as follows : Secure the best dental plaster ; rub this well into the 
meshes of strips of crinoline from two to four inches in width and six 
yards in length ; get, if possible, crinoline that is sized with starch and 
that is free from glue : if doubt exists as to the sizing, wash the strips, 
and let them dry before incorporating the plaster within the meshes. 
When the bandage is rolled — and it must not be rolled tightly — wrap a 
bit of tissue-paper around it and place it in a tin box with a good cover. 
A bandage thus prepared and thus laid away will be good for use from 
one to two or three weeks later. It is better to use bandages made the 
same day. Still, this is of little consequence if the above precautions are 
taken. 

The patient should be partially suspended or simply stretched, with 
a skin-fitting shirt over the body, and the salient points, such as the pro- 
jecting spinous processes, the iliac crest, the posterior superior spinous 
processes, the free ribs, if they project, lightly padded with eider-down 
cloth or piano felting. The eider-down cloth answers very well. With 
one or two assistants to steady the patient and keep the shirt drawn taut 
over the body the plaster may be applied in the following way : Take 
from a pail of warm water, into which two or three bandages have been 
placed on end, one bandage. Begin at the pelvis and roll the Avet band- 
age around the body, overlapping halfway at every turn. Weak points, 
as one goes up, naturally present, and these can be reinforced by revers- 
ing the bandage two or three times. Make it a point to rub every layer 
well with the hand before the next layer is applied. In the ease of 
young girls or women mammary pads of cotton batting should be em- 
ployed next the skin. These can be subsequently removed. All jackets 
should extend from the trochanters up to the axillae, and should be made 
rather heavy at top and bottom. No plaster jacket need be more than 
one-eighth of an inch in thickness. At some points where special 
strain comes it may be three-sixteenths of an inch, but it is a good plan 
not to exceed one-eighth. No salt or alum should be put into the water 



TUBERCULAR OSTITIS OF THE SPINE. 



283 



to assist the hardening process. An ordinary palm-leaf fan, when all 
the bandages have been rolled about the body, Avill aid one in securing 
the necessary hardening. Before the patient is removed from the swing 
the top and bottom of the jacket may be trimmed, and the whole process 
completed while the back is extended. Where a head-spring is neces- 
sary, the framework can be incorporated in the plaster. Where a corset 
is advisable the jacket can be cut down through the centre in front 
before it is thoroughly dry. The jacket and under-vest are removed 
together, the top- and bottom trimmed out to correspond to the axillse 
and the thighs, and the edges in front approximated, while a roller band- 
age serves to hold them in apposition. The baking process occupies 
about twenty-four hours. This is done over a kitchen range on the per- 
forated sheet iron used for drying ' 
plates. Later still, the shirt can be 
turned up over the jacket, stitched 
at the top and at the edges in 
front. A binding of chamois, kid, 
or rubber plaster can be applied 
along the front edges before the 
leather sti-ips are attached. These 
leather slips contain shoe-hooks, 
and oi^dinarily are secured by 
means of heavy thread (Fig. 292). 
Where the cervical region or cer- 
vico-dorsal' as low as the seventh 
or eighth dorsal region is in- 
volved, a chin-rest of some kind, 
or a head-spring, commonly known 
as the jury-mast, is employed, and 
the framework for this is inserted 
between the layers of the band- 
age. In other Avords, the frame- 
work is fitted after a few turns 
have been made, and the remain- 
ing turns are carried over this, 
so that a good support is thus 

obtained. The completed jacket and head-spring is shown in Fig. 
293. 

I have not included the directions for the manufacture of the wood 
corset, the woven wire, the raw hide, the leather, or the manila paper and 
glue. All corsets of this class can best be made by the instrument- 
maker over a cast which has been supplied by the physician or surgeon. 
All such supports may be classed with the steel spinal braces, because 
of the extra labor required in their construction. The steel brace which 
is the most generally employed in this country is the Taylor spinal 
assistant, an illustration of which is presented in Fig. 294. The 
Taylor brace has been modified a good deal, and it is really a very ser- 
viceable support, because modifications can be made. For instance : 
scapular pads may be attached, and in this way the scapula held in good 
position. As counter-pressure, however, for scapular pads the acromial 
cups are best employed, and Dr. Whitman has made a very useful com- 




Plaster corset. 



284 



OBTHOPJEDIC SUMGEBY. 



bination of these two attachments to this apparatus, as shown in Figs. 
295 and 296. Curiously enough, these acromial cups were used by 
Banning many years ago, as shown in Fig. 297. While indulging in 
historical lore, an old brace was used in 1744, an illustration of which is 
furnished in Fig. 299. Nuck's spinal brace with head-spring, as shown 
in Fig. 298, is certainly an improvement, so far as appearances go, on 
the woven-wire spinal brace with jury-mast. Next, perhaps, in fre- 
quency, is the Knight spinal brace. The surgical instrument-makers 
furnish the directions for measurement, but with all the instructions 



Fig. 293. 





Plaster jacket with head-spring. 



Taylor spinal assistant. 



given it is exceedingly difficult, for one who is reasonably familiar with 
the apparatus, to get a satisfactory appliance for his patient. The steel 
bars and encircling bands should be fitted before any upholstering is 
done. The measurement should depend altogether upon the length of 
the bars the individual surgeon requires for his case. No hard-and-fast 
rules can be laid down for measurements for apparatus. If the surgeon 
has a clear idea of just what he wants to meet the indications, he can, 
with a tape-measure, measure for the uprights and the cross-pieces, can 
mark off just where he wants any padding, where rivets should come, 
where shoulder-straps, head-supports, etc. etc., and can make a rude 



TVBEBGULAR OSTITIS OF THE SPINE. 



285 



drawing indicating the points on the outlines where pads, cross-bars, 
straps, etc. should come. 

The treatment of abscesses depends largely upon the efficiency of the 
protection given to the spine by apparatus. If the spine which I have 
chosen to call a broken back is well splinted, the abscess will either be 
insignificant or easily managed. In my own hands the aspirator has 
proved of greater value than incision. So long as the abscess itself is 
not in the way of the requisite support it may be left alone. Nearly all 
can be easily aspirated. My own plan is to get the skin overlying thor- 
oughly aseptic, have my needles sterilized, crowd the parts closely down 
over the tumor, and thrust the needle into the sac ; evacuate until the 
needle is filled with plugs of cellular tissue, remove the tubing, thrust a 



Fig. 295. 





Whitman scapular pads. 



Whitman shoulder-cups. 



blunt wire rod through the needle to remove the tissue, reapply the tub- 
ing to the proximal end of the needle, and withdraw more pus. After 
the sac has been pretty well emptied suddenly withdraw needle, paint 
the opening with collodion, strap the parts well over an area of two or 
three inches, and enjoin rest in bed for from six to twelve hours. In 
adult patients I employ an ice-bag over the part aspirated for several 
hours. My own experience in injecting agents of various kinds has led 
me to abandon such treatment and resort to aspiration alone. If re- 
filling takes place rapidly, and if the abscess for any reason becomes 
" hot," then an incision is made. The length of the incision will depend 
somewhat upon the locality of the abscess. Wherever it is possible a 
long incision should be made, the sac-walls should be curetted and 
thoroughly flushed until the fluid is clear, and then the opening stitched 



286 



ORTHOPEDIC SURGERY. 



together with a small point for temporary drainage. Orthopaedic sur- 
geons who have become adepts in adjusting steel braces find very little 
occasion for interference with these pus-collections. A number disap- 
pear by resorption. A certain number open spontaneously, and either 
close within a short time or continue to discharge through a sinus. I 
must enter a protest against the 

free incision of an abscess in adult Fie. 298. 

cases of Pott's disease. My own 
experience, supplemented by a 
pretty large observation, leads 
me to believe that it is next to 
impossible to avoid sepsis sooner 
or later, even by the most skil- 
ful operators. 

The deformities of the hip 

Fig. 297. 




The Banning brace. 




Nuck's spinal brace. 



and thigh which result from muscular contraction or contracture usually 
right themselves after the case comes under good protective treatment. 
There are very few cases of psoas contraction that, in my judgment, 
require any special treatment, yet where these contractions persist and 
contracture has become fully established the deformity may be corrected 
either by traction with weight and pulley or by subcutaneous or open 
incision. A treatment that has attained an ephemeral degree of popu- 
larity is the direct incision upon the bone and removal of the tuber- 
culous foci. While this may be a step in the right direction, the mor- 
tality which is already to the credit of this operation is rather against 
its continuance. At least, it is against my own suggestion in an article 
of this kind. 

To recapitulate, then, the treatment should be — 

(1) Protective, the protection absolute and extending through a period 
of from twelve to eighteen months. 

(2) At the expiration of the eighteen months, if no exacerbation has 



LATERAL CURVATURE OF THE SPINE. 287 

occurred within the past six months, a corset-jacket may be substituted 
for the solid jacket, and the protection need not be so complete. 

(3) After a period of two or three years' treatment certain precau- 
tions may be omitted, such as having the patient sleep in the support at 

Fig. 299. 




Old form of spinal brace. 

night, or having him either suspended or lying prone when the apparatus 
is removed. 

(4) The support to be used by the average practitioner, whether he be 
medical or surgical, is the plaster-of-Paris jacket or corset. 

(5) The complications are to be treated expectantly, as a rule — the 
compression-myelitis by rest and by the avoidance of electricity of any 
kind. Internal medication may be employed, my own preference being 
potassium iodide in large doses. The Paquelin cautery is frequently 
useful, but simply as an adjunct. 

(6) Abscesses should be let alone, unless they interfere with the appli- 
cation of apparatus or become painful or distressing, and interfere by 
their size with the function of important organs or other precautions. 

(7) Aspiration is preferable to incision : incision should be employed 
when aspiration fails. 

(8) Deformities resulting from muscular contractions require no 
special treatment unless they become fixed by contracture. 

(9) Good hygienic surroundings, nutrients in abundance, good climatic 
influences whenever possible. 

Lateral Curvature of the Spine. 

The synonyms for lateral curvature of the spine are Rotary lateral 
curvature. Scoliosis, and Spinal curvature. It is not customary to intro- 



288 



ORTHOPEDIC SURGERY. 



duce Pott's disease and lateral curvature in such close connection, but 
one can give a better idea of the deformities that belong to these two 
orthopaedic subjects by introducing them in this order. 

Definition. — Lateral curvature of the spine is not a disease of the ver- 
tebrae, but is, more properly speaking, a lack of symmetry of the two 
sides of the body brought about by a rotation of the vertebrae on the 
vertical axis, this rotation of itself inducing a lateral deviation of the 
column. So that the term " lateral," as applied to the curvature, is a cor- 
rect one, and is sxifficiently significant to enable one to distinguish the 
curve from the angular deformity of Pott's disease ; which deformity, 
when it rarely assumes the shape of a curve, is an antero-posterior curve. 

Etiology. — There is really no deformity of the human body which 
presents more difficult problems etiologically than does scoliosis. The 
various theories may be enumerated in the following order : Congenital 
asymmetry of the articular facets of the lateral masses ; rhachitic changes 
in these facets, inducing the asymmetry ; faulty positions long maintained 
during the early period of life ; muscular asymmetry dependent upon 
some obscure disturbances of the nerve-centres ; faulty attitudes at school, 
either in standing or sitting. In tracing the causes in individual cases I 
have been impressed with the frequency with which lateral curvature 



Fig. 300. 




Lateral curvature from myositis ossificans. 

develops in very early life, and it has occurred to me that the greater 
number might be traced to rhachitic changes, such changes brought about 
by carelessness in supporting the child while the bones were yet soft, and 
the failure on the part of the mother or nurse to maintain correct atti- 



LATERAL CURVATURE OF THE SPINE. 



289 



tudes. The rhachitic theory is not a good working theory, because 
parents themselves are not aware of the presence of rickets, the children 
are usually treated for disturbances of digestion and various minor ills, 
while the physician himself dislikes to apply the term " rickets " to cases 
occurring in children in the better walks of life. The parents, therefore, 
become aware only after the deformity has developed that the child has 
passed through the rhachitic stage. 

While predisposing causes are so uncertain, it behooves us to look for 
exciting causes. Among these may be mentioned faulty attitudes at school 



Fig. 301. 






Fig. 302. 




A common type of lateral curvature 



Lateral curvature from poliomyelitis. 



long continued, faulty positions in standing, whether at home or in school. 
Errors in refraction may lead to lateral curvature, because the child must 
needs bend forward in order to read or study with any degree of com- 
fort. The occurrence of lateral curvature upon the right side so fre- 
quently is due largely, it seems to me, to the increased use of the right 
side brought about by vocations in general. 

A very rare cause of lateral curvature of the spine is myositis ossiii- 
cans. Fig. 300 is a case that was for many years under my observation, 
and I had an opportunity of observing the case through its different 

Vol. II.— 19 



290 ORTHOPJEDIC SUBOEBY. 

stages. Poliomyelitis is a not infrequent cause of lateral curvature. It 
occurs not so much from paralysis of the muscles of the body as from 
paralysis of the muscles of the extremities. For instance : a deltoid par- 
alysis Avill give rise to a curvature on the opposite side. Crural asym- 
metry of any kind will often produce a lumbar curve, while the extreme 
loss of power that is associated with a dangle-leg often results in a mod- 
erate grade of spinal curvature. Indeed, the case which is represented 
in Fig. 302 is of this type. And, last but not least, crural asymmetry 
is the most frequent cause of lumbar curve. 

Pathology. — The pathology is well understood. It is a lack of sym- 
metry between the two sides of the vertebrae, a rotation of the vertebrae 
upon the vertical axis, a wedge-shaped condition of the vertebrae, a bend- 
ing of the ribs near the spinal articulations, besides numerous changes in 
the thoracic walls and cavity. The involvement of the spinal cord or 
the meninges is exceedingly rare, yet there are on record cases showing 
disturbances of muscular nutrition, various forms of neuralgia, and even 
paraparesis, clearly dependent upon the pressure on the cord, and espe- 
cially on the nerves at the foramina of exit. A true ostitis is rarely 
present, and when it is present it is confined to the edges of the ver- 
tebrae or the lateral masses, and is secondary to, or dependent upon, the 
pressure of these parts one upon the other by reason of the distortion 
and the shortening of muscular tissue. The text^book's are so re- 
plete with illustrations of the scoliotic spine that I have refrained from 
presenting the customary figures. 

Clinical History. — The changes that lead up to a well-marked rotary 
curvature of the spine are so insignificant and so very slight that one 
seldom encounters a case in what is known as the very early stage. The 
attention is generally first called to the deformity by the dressmaker or 
by the mother herself when she is fitting garments, and attention is then 
called either to what is known as the " angel-wing " or to the high hip. 
By " angel-wing " is understood the undue prominence of one scapula. 
The lower angle is on a plane much posterior to the lower angle of the 
other scapula. The body of the scapula is raised from the chest-walls 
apparently, so that the vertical plane of the body itself is posterior to the 
vertical plane of the body of the other scapula. By the high hip is under- 
stood the prominence of one iliac crest over that of the other. This is 
due to obliquity of the pelvis, and associated with the high hip is a deep 
ilio-costal space. The prominent scapula is associated with the earliest 
stages of a lateral curvature. It is true that to detect the prominence of 
this bone an observant eye is often called into requisition ; but rotation 
of the vertebrae cannot take place without a projection of the ribs 
on the convex side and a depression of the ribs on the concave 
side. This projection will, of necessity cause change in the ap- 
pearance of the scapula. Long before any actual lateral deviation 
occurs the rotary element is present, and the lateral deviation appears as 
the rotation becomes more pronounced. Next in order of frequency we 
have a lack of symmetry between the tips of the shoulders. One is a 
little higher than the other. The acromion process is on a plane ante- 
rior to the acromion process of the other side. Among other signs we 
have a lack of symmetry between the ilio-costal spaces — the one is rather 
deep, the other long ; the actual deviation, with a compensatory devia- 



LATERAL CURVATURE OF THE SPINE. 291 

tion on the opposite side, the curve resembling a letter S ; the recession 
of the chest^walls on the concave side, with a tilting of the lower angle 
of the scapula toward the vertical line ; an unequal mammary develop- 
ment ; a narrowing of the chest-walls anteriorly ; and often an obliquity 
of the pelvis. The pigeon-breast or " bird's-nest " deformity is frequently 
associated with lateral curvature, and their presence rather confirms the 
rhachitic origin of the distortion. As the deformity increases from month 
to month, or sometimes from year to year, the patient is shortened in 
stature ; the angel-wing becomes more prominent ; the ribs on that side, 
in fact, form an enormous bosse known as hunchback ; the axilla on the 
concave side approaches quite closely the iliac crest ; the free ribs are 
unduly prominent ; and the patient has a very awkward gait. In Fig. 
301 we have a lateral curvature, with the spinous processes dotted in 
order to bring out in more prominent relief the actual lateral deviation 
and the letter S curve. In order to represent an extreme degree of 
lateral curvature I have introduced Fig. 302. This occurred in a child 
with poliomyelitis, and the extreme distortion here noted is largely de- 
pendent upon the paralysis which developed in early life. 

Diagnosis. — In the deformity now under consideration early diagno- 
sis is quite as important as in any deformity within the range of ortho- 
paedic surgery. Lateral curvature which is well advanced does not 
require any special skill in diagnosis, and it is only necessary to note 
the characteristics of a lateral curvature to differentiate this from the 
deformity of Pott's disease, or from round shoulders, or rhachitic kypho- 
sis, or irritable spine. An early diagnosis presupposes a knowledge of 
the normal positions of the scapulae, the symmetry of the chest-walls, 
the symmetry of the iliac crests, and the normal anatomy of the spinal 
column itself. 

A routine examination is the first step in diagnosis, and the points 
for observation are the following : The relationship of the scapulae one 
to the other ; observe whether they are symmetrical ; observe the ilio- 
costal spaces ; note whether one is deeper than the other or one longer 
than the other; note the position of the tips of the shoulders, the 
acromion processes ; then have the patient bend forward at the hips, 
knees perfectly straight, and note whether the chest-walls on one side 
are more prominent than those on the other ; note the prominence or 
recession of the transverse processes ; dot the spinous processes, and 
let a plumb-line fall from the vertebra prominens, and draw a line 
with a dermatograph or pen along the line — the slightest deviation can, 
in this way, be detected ; learn the habitual attitude of the patient. In 
making a differential diagnosis one must distinguish between a slight 
rotary curvature and an irritable spine. In irritable spine we have 
intercostal neuralgia, tenderness along the spinous processes, and espe- 
cially on eitlier side of the spinous processes. This condition is so 
closely allied to hysterical spine that tenderness on pressure may be 
found at various bony points. From round shoulders the diagnosis can 
be made by the tests above given. 

Treatment. — No hard-and-fast rules can be formulated for the treat- 
ment of lateral curvature. The ideal treatment is properly supervised 
medical gymnastics. The use of apparatus is occasionally called for, 
an out-of-door life with the tonic effects of a bracing atmosphere, regular 



292 ORTHOPEDIC SURGERY. 

hours for eating and sleeping ; in other words, a good hygiene enters 
largely into the therapeutic formulary for lateral curvature. It is diffi- 
cult to determine always just how much exercise a child shall take or 
how the exercise shall be taken. Suffice it to say that any exercises 
which are prescribed ought to be not only taught, but insisted upon. 

For convenience curvature may be divided into three classes : (1) 
the incipient curve, which presents very few changes and a scarcely 
appreciable deformity ; (2) the well-marked curve, associated with the 
rotation of the vertebrae, prominent scapula, prominent ribs, and unsym- 
metrical ilio-costal spaces; (3) the exaggerated curvature, with great 
deformity, an unyielding spinal column — what is known as a rigid col- 
umn — associated usually with a low grade of muscular development and 
distortion of the thoracic walls and vertebrse. 

In the first class the rule is not to apply any form of apparatus. 
Even shoulder-braces should be discouraged. Light gymnastic exer- 
cises, employed symmetrically, are amply sufficient. The muscles can 
be very well developed in any gymnasium, provided the patient attend 
the gymnasium with any specific purpose in view. It is quite essential 
that the patient should devote more time to athletic pursuits of all kinds 
than is usually prescribed, and that the hours for study, both at school 
and at the piano, should be shortened. So far as my own experience 
goes, the family practitioner has, when these cases have been recognized, 
been able to afford relief by attention to ordinary hygienic rules. It is 
well to submit the case to an occasional critical observation, in order that 
more heroic measures be employed should the deformity belong to the 
actively progressive kind. 

In the second class gymnastic exercises are always desirable, and are 
to be preferred to any form of apparatus. The exceptions are — stupidity 
on the part of the patient, and sluggishness and a failure on the part of 
the parents to appreciate the importance of close attention to details in 
gymnastic practice. To bring this out in better relief: Given a child 
who is either too young or too inattentive to learn well a series of exer- 
cises, it is useless to follow this course longer than one or two months : 
we must supplement the exercises with an appliance of some kind ; and 
for the average practitioner there is nothing quite so good as the plaster- 
of-Paris corset, worn the greater part of the day, taken off toward 
evening, and dispensed with until the following morning. Again, some 
children, although old enough to appreciate the advantages of this treat- 
ment, seem to lack gray matter. They are stupid, dull ; they fail to 
study at school — fail to apply themselves at anything which requires any 
effort or a reasonable amount of intelligence. The combination of exer- 
cises with apparatus is not generally regarded as the best form of treat- 
ment, yet there are some very good orthopaedic surgeons who not only 
combine apparatus with active exercises, but devote a good deal of per- 
sonal attention to forcible movements, day by day, with the idea of 
correcting the rotary element. They admit, as we all do, that apparatus 
of itself, no niatter how skilfully constructed and how accurately applied, 
fails to untwist ; but in the skilled hands of the surgeon an impression 
can certainly be made upon the rotary element. 

It is difficult in a work of this kind to describe the various exercises. 
My own plan is to follow, as nearly as possible, the list given by Mr. 



LATERAL CURVATURE OF THE SPINE. 



293 



Fig. 303. 



Bernard Roth of London, and to supplement these with forced move- 
ments, adding from time to time other exercises as the case seems to 
demand. A good working list is the following : 

(1) Respiratory. — Insist upon the patient standing erect. Then, with 
a dumb-bell grasped in each hand, take a full inspiration with the mouth 
closed, and hold the breath as long as possible ; then open the mouth 
and gradually exhale. Let this inspiration and expiration be repeated 
five or six times. Witli the arms and hands 
fully extended above the head, still grasping 
the dumb-bells, repeat the procedure. 

(2) Head Rotation. — With the dumb-bells 
grasped tightly, arms by the side, and shoul- 
ders well back, rotate the head from side to 
side to the fullest extent, throwing into the 
movement all the muscular force that is pos- 
sible. Do this from fifteen to twenty times. 
Let the patient count aloud every one of 
these rotations of the head. 

(3) Lateral Flexion of the Head. — Same 
position as in 2, with the head rolled vigor- 
ously from side to side toward the shoulders, 
counting as above. 

(4) Circumduction of Arms. — With fore- 
arms extended, dumb-bells well grasped, 
make as complete circumduction as is pos- 
sible with the arms from the shoulders. 
From ten to twenty times will be sufficient. 

(5) Pugilistic. — This is a mere arbitrary 
name for this exercise, which is done as fol- 
lows : The patient standing erect, shoulders 
well back, forearms extended on the arms, 
extend both arms forward at a right angle 
with the body, palm upward ; clinch the bells 
tightly, then flex the forearm vigorously on 
arm, while the arm falls to the side and is 
even forced backward, then extend ; flex the 
forearm as before ; extend the arm from the 
side with palm upward ; bring the whole 
arm, with forearm fully extended, down 
forcibly against the side. This exercise may 
be repeated -from seven to ten times. 

(6) Key-note. — With dumb-bells grasped 
tightly extend the arm and forearm of the 
concave side well above the head, and the 
other arm and forearm extended laterally from the side at a right angle 
with the body. Now let the patient, with arms in the position just 
described, rotate back and forth to the fullest extent the upraised arm, 
counting one for a complete revolution. Repeat this ten times. (See 
Fig. 303.) 

(7) Four Count. — With dumb-bells, bring the arm forward from the 
side of the body to a right angle, forearms fully extended, palms facing ; 




Key-note position. 



294 ORTHOP-iEDIC SURGERY. 

throw the arms well back, and then strike the ends of the dumb-bells 
briskly against each other back of the hips. As they rebound strike the 
second time. Kepeat this movement from eight to ten times. 

(8) Anvil Stroke. — Starting in the same position as above, bring the 
arms back of the body with forearms fully extended, and by a rotary 
movement of the shoulders strike the dumb-bells together, first one end, 
then the other. This should be done from ten to twenty times. 

Additional exercises may be added to those just given, and i-esistance 
may be offered in a variety of ways. Heavy dumb-bells may be lifted 
from the floor and carried to the extreme point above the head. Exer- 
cises may be given to the lower limbs with the patient lying both prone 
and supine on a table. Indeed, the surgeon can devise a variety of 
means which will tend to correct the curvature and at the same time 
bring out in full development the muscles which seem to be weak. It 
must be remembered that all exercises should be light and infrequent 
at first, that heavier weights should be used as the muscles develop, and 
that adequate periods of rest should be insisted upon, both while the 
patient is drilling under the eye of the surgeon and under the eye of 
the mother or nurse at home. From a half hour to an hour a day is 
little enough to devote to these exercises. After they have been well 
learned they should be continued every day for from one to two or 
three years. 

Self-suspension in the swing has not had the reputation of effecting 
much relief. A very fair illustration of the improved position is shown 
in Figs. 304 and 306. 

My aim in outlining a course of exercises has been to present such 
as any surgeon or physician can employ in his own office and without 
the aid of various appliances for forcible correction. The apparatus of 
Hoffa, the bars of Lorenz, and the usual devices employed in a gymna- 
sium have not been presented, because they are not only difficult to keep in 
order, but because the results obtained from these devices have not been 
sufficiently gratifying to enable me to urge them upon the consideration 
of the readers of this article. The management of a case of lateral 
curvature in a wellrto-do family is sufficiently easy, for the reason that 
the time can be given for treatment — the families themselves are inter- 
ested in the improvement noted ; but among the poor and the shiftless 
the management of such cases is exceedingly difficult. Among this class 
may be noted working-girls, whose time is taken up throughout the 
entire day, and who are really too much worn out to drill or practise 
in the evening. At the Hospital for the Euptured and Crippled 
attempts are being made from time to time to treat the school-girls 
among the poorer classes, and, while much is being accomplished, it 
is very difficult to carry out any form of treatment to a satisfactory 
issue. 

In estimating the amount of relief afforded, the scoliosometer, em- 
ployed at long intervals, may be advised, but the ideal instrument is yet 
to be devised ; and, after all, one relies more on his own observations 
carefully made at stated intervals, and on the reports that come from 
the mother, the teachers, or the dressmaker. Such reports as the follow- 
ing are very suggestive. From the dressmaker, for instance: "Less 
padding is required. It is easier to fit the dresses." From the mother 



LATERAL CURVATUBE OP THE SPINE. 



295 



or nurse : " The girl holds herself in much better position. It is no 
longer necessary to insist upon her holding herself straight," etc. etc. 

In the treatment of the third class the plaster-of-Paris jacket and the 
various forms of steel braces are really necessary to prevent a further 
increase in the deformity. Illustrations of the various braces are omitted, 
for the reason that no one is universally recommended, and the claims 
for any one in particular are that it 

simply prevents increase in deform- Fig. 305. 

ity. The advocates of mechanical de- 
vices usually supplement with gym- 
nastic exercises and forced move- j im 
ments. In my own hands the solid J / -a_ 



Fig. 304. 





Self-suspension in the swing. 



plaster-of-Paris jacket applied at intervals of from two to three months, 
and applied with the patient self-suspended to the utmost limit and 
under a great amount of lateral pressure, has yielded the best results. 
In a number of instances I have been enabled to convert an old rigid 
curve into a flexible curve, and have been enabled, after from six to 



296 



OBTHOPMDIC SURGERY. 



eight months of this kind of treatment, to employ the medical gym- 
nastics as above described. 



Oldb-poot. 

Varieties. — By " club-foot " is meant a deformity of the foot, either 
congenital or acquired, involving extension, flexion, inversion, eversion, 
or rotation. Extension and inversion are usually associated, and less fre- 
quently still extreme flexion. The synonyms are Talipes and Reel-foot. 
The German name is Klumpfuss ; the Latin, Pes contortus ; the French, 
Pied bot. The term talipes is generic, and the various modifications are 
talipes varus, valgus, equinus, and calcaneus. 

Varus may be described as an elevation of the inner border of the 
foot, with the sole turned inward, while the anterior portion is adducted. 
The patient stands on the outer border and upper aspect of the foot. 
Valgus is directly the opposite to this, and is an exaggerated form of 
flat-foot. Equinus is an elevation of the heel, so that the weight is 
borne on the toes and ball of the foot. Calcaneus is just the reverse : 
the front of the foot from the arch to the toes is raised from the floor, 
the tendo Achillis is much elongated, and the weight is borne altogether 
upon the heel. For purposes of memory : Varus is an in-turning of the 
foot, valgus an out-turning ; equinus is a raising of the heel, calcaneus 

Fig. 306. 




Equinus. 



a depression. Talipes equinus is shown in Fig. 306. This is an ex- 
treme ease, and must not be regarded as a Aery common one. Both 
varus and valgus are shown in Fig. 307. Talipes calcaneus is illus- 
trated in Fig. 308. The different varieties thus given are by no means 
common. It is seldom that one finds a typical form of equinus, varus, 
valgus, or calcaneus. Yet a typical equinus is not so rare. A form of 
congenital club-foot that is exceedingly common is equino-varus, and, 
as will be easily recognized from the name, it is a combination of equinus 
and A-arus, the equinus predominating. AVe occasionally employ the term 
varo-equinus. This is when the varus predominates. Equino-valgus is 
a deformity not infrequently met with, and is rarely if ever congenital. 
Calcaneus is nearly always acquired, and depends, as a rule, upon polio- 



CLUB-FOOT. 



297 



myelitis. Another form of talipes which is usually associated with cal- 
caneus is known as cavus, and this is shown very well in Fig. 308. 
It will be noted that the anterior portion of the foot is slightly flexed in 
the middle portion, and leaves a transverse furrow in the sole, just back 



Fig. 307. 



Fig. 308. 





Varus and valgus. 



Calcaneus associated with cavus. 



of the ball of the foot. It is well to state that a cavus is not always 
associated with a calcaneus, but is sometimes seen in mild cases of 
equino-varus. The ti'ansverse furrow which is characteristic of the 
cavus is nearer the heel than in that form of cavus associated with cal- 
caneus. A form of club-foot which has been described by Shaffer of 
New York is known as non-deforming club-foot. This is simply a very 
mild grade of equinus, or, as it has been described, a mild form of club- 
foot, with the elements of the deformity present, but the deformity itself 
absent. 

Etiology. — We have two forms, etiologically speaking, the congeni- 
tal and acquired. By congenital of course it is understood that the 
deformity is noted at birth, and by acquired, that it has occurred sub- 
sequent to birth. Equino-varus is nearly always congenital, calcaneus 
rarely ever congenital, valgus is rarely congenital. The acquired forms, 
then, are calcaneus, equinus, valgus, and cavus. 

When we say that a deformity is congenital, we simply state an obser- 
vation made at birth. Dr. W. E. Townsend has very carefully analyzed 
2386 cases of club-foot under observation at the Hospital for the Ruptured 
and Crippled. His paper is published in the Tranmctionn of the. Medical 
Hocictji of the State of New York, 1890. The results of this analysis are 
summed up as follows : 

" Club-foot among most frequent of congenital deformities ; congeni- 
tal club-foot less frequent than non-congenital ; males more often affected 
than females. 



298 ORTHOPMDIC SURGERY. 

" Equino- varus the most frequent deformity, constituting about three- 
quarters of all the cases. 

" Both feet more often affected than one. 

" Right foot more often affected than the left. 

" Non-congenital club-foot most frequently due to paralysis. 

" The paralytic forms usually due to poliomyelitis. 

" One foot more often affected than both. 

" Flat-foot more commonly affects both feet. 

" Males and females about equally affected in non-congenital club- 
foot. 

" Equino-varus, equinus, and calcaneus most common forms of para- 
lytic club-foot. 

" When both feet are affected, the deformity is usually the same on 
each foot. 

"Equinus and calcaneus are rare as congenital deformities, but 
common as paralytic." 

The cause of congenital club-foot is still enveloped in more or less 
obscurity. Various theories have from time to time been propounded, 
and these theories have been stoutly maintained by their various advo- 
cates. It has been sufficiently proven, in the opinion of the writer, that 
paralysis is not a cause of congenital club-foot. The best working theory 
is that first propounded by Essericht of Copenhagen, later elaborated by 
Berg of New York and Parker of London. (See page 267.) After all, it 
is not a theory a thorough understanding of which will enable one to 
prevent the occurrence of club-foot, because all the changes are occult, 
and because there is nothing during the development of the foetus which 
can be recognized by the physician or surgeon. Just how maternal im- 
pressions may produce an obstruction to rotation we are at a loss to 
understand. Suffice it to say, that maternal impressions are beyond our 
control as a rule, and as yet we have no means of preventing a congenital 
deformity or arrest of development. 

We are much more familiar with the causes which produce acquired 
talipes. One of the most frequent is a poliomyelitis anterior. In this 
disease of the spinal cord we have, as a result, more or less complete par- 
alysis of the gastrocnemius, which gives us calcaneus ; of the anterior 
tibials, which gives us equinus ; of the anterior tibials and the peroneals, 
which gives us equino-varus ; of the interossei, whicli gives us cavus : and 
of the posterior tibials and the anterior tibials, \vhich gives us valgus 
and equino- valgus. Injuries to the foot, such as unrecognized and un- 
treated sprains, sometimes result in talipes. Disease of the tarsal and 
metatarsal bones results quite frequently in talipes. Any compression of 
the foot may produce talipes. The treatment of the Cliinese foot invaria- 
bly produces a high degree of cavus. Injuries about the leg involving 
either the bone or soft parts result occasionally in a form of club-foot. 

Pathology. — The pathological changes involve the bones, the liga- 
ments, tendons, and muscles. Where the tendons and muscles are alone 
involved, the changes are of little consequence and correction of the de- 
formity is easily accomplished. This rule hardly applies to the congeni- 
tal forms of club-foot, because the muscular and tendinous changes have 
occurred during foetal life, and before treatment can be begun already 
the ligaments and bones, or at least the elements of bone, have been so 



CLUB-FOOT. 299 

altered in shape that at birth we have changes involving all the struc- 
tures in the foot. Without going into too elaborate detail, it may be 
stated that the scaphoid is altered in shape and its facets are changed. 
The bone itself becomes smaller, the cuboid becomes larger and more 
wedge-shaped. The facets on the head of the astragalus are changed to 
accommodate the adjoining bones in their displaced positions. The os 
calcis is elongated in its anterior portions. The deltoid ligament is short- 
ened, the outer ligaments are lengthened. The plantar fascia is short- 
ened. The structures in this locality are also shortened. The tendons 
on the outer side are elongated, and as growth goes on these changes be- 
come more marked. The pathology of an acquired club-foot is very 
similar to that of congenital, except that the bony changes are never so 
pronounced. An explanation of this can be liad in the ossification of 
certain bones before the occurrence of the lesion which produces the 
deformity. 

Diagnosis. — There is so little in the clinical history that the usual 
paragraph is omitted, and, indeed, there is so little to diagnose that ^ve 
might well omit this, for the reason that a knowledge of the varieties of 
club-foot is suificient to enable one to recognize the deformity. It 
may be desirable, however, to call attention to points in differential 
diagnosis between club-foot and weak ankles. 

A young child may have a specially long tendo A chillis or much lax- 
ity about the ligaments of the ankle, and the foot can be brought into 
marked calcaneus. One is consulted occasionally about a deformity of 
this kind, and it is only necessary to compare the measurements of the 
calves and to test the functions of the muscles to eliminate any genuine 
calcaneus. Again, when the child begins to walk a pseudo-equinus is 
observe. The child does not get the heel to the floor well — prefers to 
walk on the toes and balls of the feet. This is a source of alarm to the 
parents, and advice is frequently sought. It needs only careful exami- 
nation to eliminate any equinus. If the foot can be flexed passively 
beyond 90°, there is no equinus. Rhachitic children present often 
weak ankles. Some look upon this weakness of the ankle as genuine 
valgus, but the deformity is so easily corrected by slight pressure from 
the finger or thumb that club-foot is easily excluded. In children of 
older growth, and even in patients who are adolescent, there is often 
a slight equinus depending upon an old poliomyelitis, with verj- slight 
paralysis. By comparing the calf measurements and by testing the func- 
tions of the foot actively and passively one can readily decide upon the 
shortening or not of the tendo Achillis. 

The grosser forms of club-foot are so easily recognized, and so easily 
understood, that further discussion of the subject is unnecessary. 

Treatment. — This may be divided into manual, mechanical, and 
operative. 

Manual Treatment. — By manual treatment is meant the attempted 
correction of deformity by the use of the surgeon's hand or the hand 
of the masseur, the nurse, or the mother even. It not infrequently hap- 
pens that the monthly nurse is competent to correct a mild grade of 
club-foot if recognized by the accoucheur. Whether slie succeeds or not, 
it is at least an important preliminary step to the other forms of treat- 
ment. While the bones are still unformed and while ossification is as 



300 ORTHOPEDIC SURGERY. 

yet rudimentary, a great deal can be done by the intelligent handling of 
a club-foot although the deformity be of the highest grade. The fre- 
quency with which the baby must be handled makes the manual treat- 
ment quite practicable. The plan simply is to grasp the front of the 
foot with the hand and unt\\'ist, making extension and eversion, subse- 
quently flexion of the foot, rubbing the parts on tension with the fingers 
and thumb of the other hand. The stretching can be made rather sharp, 
and then the force be loosened, the foot being held for a half hour or 
longer in a corrected position. I am sure that sufficient attention has 
not been given to this important branch of treatment, and I need not 
apologize for calling attention to it now. Manual treatment can be 
begun, therefore, at birth, and continued up to the second or third month 
without compromising in the least any subsequent mechanical treatment. 
If such measures can be employed intelligently and faithfully, then the 
mechanical treatment can well be postponed until the third or fourth 
month. The question which is so often asked, When shall the treatment 
of club-foot be begun ? may be answered as above. 

Mechanical Treatment. — By this is meant the gradual or instantane- 
ous correction of the deformity by means of apparatus; in fact, by 
splints of any kind. Even in the adjusting of an apparatus a great deal 
of manual dexterity is required. The foot, for instance, can be held 
by the hand in an excellent position while an unyielding apparatus is 
adjusted ; for instance, the application of a straight splint in the shape 
of a bit of cigar-box or steel to the outer side of the limb from the 
head of the fibula down past the external malleolus to the toes, the 
equino-varus having been converted by manipulation into pure equinus. 
In the judgment of the writer it is very important to correct — and 
indeed, over-correct — the varus before any attention is given to the 
equinus, for the reason that the correction of equinus is very simple, 
and the more pronounced the deformity, the easier the correction ; but 
this is not true of varus. A much longer time is required, whether one 
employs a splint with screw for daily stretching, or whether one employs 
manual force once a week or once in a fortnight and holds the foot in 
good position by plaster of Paris. The important feature, therefore, is 
to over-correct the varus before any attention is given to the correction 
of the equinus. In the new-born this is by all means the best plan to 
pursue, and in older children where relapse has occurred the correction 
of the varus first is very nearly as important. 

Among the appliances for mechanical treatment may be mentioned in 
the order of availability the following : The straight splint made from 
a bit of cigar-box or from bar steel ; plaster of Paris ; the club-foot shoe 
of Hugh Owen Thomas, which consists of a single bar of steel to pass 
from the calf to the sole of the foot, and bent at the heel at an exag- 
gerated right angle, the ends attached to a piece of sheet steel, one of 
which shall partly encircle the calf, the other partly encircle the ball 
of the foot ; the Knight club-foot shoe, the Taylor, the Shaffer. The 
old-fashioned Scarpa's shoe is not employed by orthopaedic surgeons, so 
far as I know, but is frequently supplied by the instrument-maker when 
order is given in general for a club-foot shoe. 

The straight splint can be made available by any practitioner. The 
board needs to be padded well and the padding held in place by a com- 



CLUB-FOOT. 301 

mon flannel bandage. One end is fastened to the calf by a broad band 
of adhesive plaster ; a pad is placed just above the malleolus while the 
varus is converted into equinus, and the lower end of the splint is fast- 
ened by adhesive plaster, with the ball of the foot well padded to the 
end of the foot. In obstinate cases, where the varus cannot be imaiedi- 
ately converted without an anaesthetic into a pure equinus, rather broad 
bar steel, padded well, can be made use of to great advantage, because 
one can shape it to the deformity in its different stages. These steel bars 
can also be used for the correction of equinus, and in a number of in- 
stances I have myself completely corrected both the varus and the 
equinus without an ansesthetic, without any operation, but by simply 
shaping the bar steel from time to time to the position gained by manual 
force. When it is necessary to over-correct the varus at once, it is best 
to give an ansesthetic, and my preference is for ether to the primary 
stage. The foot can then, during the few moments that the anaesthesia 
is complete, be forcibly brought into the over-corrected position and held 
while the splint or plaster of Paris is applied. To prevent the splint, 
if the steel bar be .used, from slipping, an adhesive strip or two should 
be applied in the upper and lower portions, after which a roller bandage 
from the toes to the knee will secure the good position obtained. From 
two to four Aveeks later the equinus can be corrected by a division of 
the tendo Achillis, under primary anaesthesia preferably, otherwise with- 
out an ansesthetic, and the equinus converted into a calcaneus. The 
curved steel bar applied posteriorly or the plaster-of-Paris bandage 
may be employed at this operation, and the foot held in position for 
from two to four weeks, according to the amount of time at one's 
disposal. 

The further treatment of the case, whether the deformity shall have 
been corrected rapidly or slowly, should be continued by the use of the 
Knight club-foot shoe, which may be described as follows : A foot-plate 
of steel, the shape of the foot ; an upright counter of steel which shall 
pass from one malleolus under the foot-plate to the other malleolus ; a 
heel-cup of leather which shall pass from this steel counter from one side 
to the other ; a steel spring on the outer side extending from a joint at 
the ankle, and on the outer portion of the steel counter, up to a calf- 
band, which shall be of sheet steel about one inch in width, and encir- 
cling the upper portion of the calf two-thirds of its extent ; the remainder 
completed by a band of leather, which lines the steel calf-band and is 
buttoned or buckled to the upper end of the upright bar. The whole 
appliance, thus completed in the rough, should be lined with kid or 
shaved sheep. The heel can be secured by means of an inslep-strap, 
which consists of a padded triangular piece of soft leather to the end of 
which long tapes are sewn. These tapes pass next the foot and back 
of the steel counters and up over the outer sides to tie over said trian- 
gular pad. 

To apply the apparatus, then, the foot can be placed on the plate with 
the heel back well into the heel-cup and between the steel counters, a 
stocking over the foot if desirable. The instep-strap is then applied so 
as to hold the heel well into the cup. Finally, the steel upright and calf- 
band can be brought into position. The joint at the ankle should be a 
simple hinge-joint with a steel peg just below the rivet and in front of the 



302 OETHOPJEDIC SUROERT. 

distal end of the steel upright. We can thus hold the foot at a right 
angle with the leg, or, if it is necessary to increase the angle — that is, to 
make it more acute — the steel peg just referred to can be set farther 
back. 

After the Knight club-foot shoe has been thus adjusted, if the toes 
incline to eversion and overlapping at the inner border of the plate, a lip 
can be riveted to the plate, or the plate in the first instance can be cut so 
that the lip can be turned up, and thus make pressure against the foot 
immediately back of the ball of the great toe. This lip need not be more 
than a half inch in height, or even less than this. If a leather shoe is 
employed at once, there is no need for a roller bandage over the foot to 
secure it to the plate, but at night this will be a very good precaution to 
take, for it must be remembered that the club-foot shoe is to be worn 
night and day — that it is never to be left off longer than just time 
enough, twice a day, to employ a little domestic massage and manipula- 
tion of the foot, the object of which is to over-correct and mould it into 
a better shape. When these manipulations are made the dorsum of the 
foot, just over the instep, can be bathed with alcohol and water, half-in- 
half, or borax-water — anything that will harden the skin. If excoria- 
tions occur, then appropriate padding can be employed to prevent further 
destruction of tissue. 

Too much stress cannot be laid upon the necessity for maintenance 
of the good position obtained by the above procedures. It is easy enough 
for any surgeon to correct the deformity of club-foot, but it is very diffi- 
cult for one to maintain the foot in a good position over a period long 
enough to ensure changes in the facets of the bones, full elongation of 
shortened ligaments, and the shortening of muscles and tendons on the 
outer side of the foot. One year is none too long to wear apparatus of 
the kind just described after the complete correction of the deformity. 
Certain difficulties will be encountered during the progress of this con- 
valescing treatment which it is well to note : 

(1) The child, when it begins to walk, will most surely toe-in or walk 
pigeon-toed. This objection will be offered by the parents, and the phy- 
sician himself may feel that it is an objection which should be met very 
promptly. But let me say that it is not a serious objection by any 
means — that there is no occasion, as a rule, for apparatus to extend 
above the knees or to the hips in order that the whole limb may be 
rotated outward, but have a little device, sucli as a bit of sole-leather, 
tacked on to the outer border of the sole from the shank of the shoe 
around to the inner border of the tip of the sole, and made from a quarter 
to tliree-eighths of an inch in height just at the outer border of the tip of 
the toe. This can be put on by a shoemaker and made so that it will 
appear neat and inconspicuous. Then the child can be taught to turn 
the foot out as it walks. This will i-equire a little patience on the part 
of the mother or nurse, but it will be good drilling. 

(2) The heel may not remain in the heel-cup during the entire day or 
even during the niglit. Let the parent be instructed to remove the appa- 
ratus and secure the heel in good position whenever she finds it slipping 
up, even if it be a dozen times a day. It may be necessary to assist in 
holding it in position by means of a figure-of-8 roller bandage. When 
the heel does slip up, it is a sign that the tendo Achillis is not long 



CLUB-FOOT. 



303 



enough, and there may be necessity for further stretching or division of 
the tendon. 

(3) The apparatus may get out of order, and most assuredly will get 
out of order. The surgeon should fully understand what the object to 
be attained is, and he should see that the appliance is kept in good 
repair. 

The above remarks on the after-treatment, or the treatment during 
the convalescing stage, pertain to the management of the case irrespective 
of the kind of apparatus that has been used or the means that have been 
employed, operative or otherwise, for the correction of deformity. 

The Thomas club-foot shoe was emploj-ed by the late Mr. Thomas 
with excellent result. This is secured by means of a roller bandage, and 
can be applied with or without an anaesthetic. It was his custom not 



Fig. 309. 



Fig. 310. 





Taylor club-foot shoe. 



Shaffer's modification of Taylor's ankle-brace. 



to employ an antesthetic, but to forcibly flex the foot into good position 
in spite of the pain produced, and then fasten the foot to his apparatus. 

Inasmuch as I have begun with the club-foot shoes, I shall proceed 
to a consideration of those employed by Taylor and Shaifer, reserving 
the plaster of Paris for a later paragraph. 

The Taylor apparatus is very similar in construction to the Knight, 
with the exception that the upright bar is on the inner side of the leg, 
and the foot is pushed out rather than pulled out. The plate is very 
similar to the plate of the Knight shoe, the lip being on the inner side, 
instep strapped down to the plate by means of webbing, while a similar 
stop-joint is employed at the ankle. In some respects this is an improve- 
ment on the Knight, especially in those forms of club-foot where one is 
apt to get excoriations from pressure over the outer side. Indeed, the 
advocates of the Taylor shoe claim that an excoriation is never pro- 
duced, and that one can the more readily move the foot into shape by 



304 



obthopjEoic surgery. 



pushing instead of pulling. Again, the calf-band of the Knight shoe is 
replaced in the Taylor apparatus by a broad plate on the inner side of 
the leg, which is laced to the calf and which distributes the pressure 
over a larger area. An illustration of the Tavlor shoe is presented in 
Fig. 309. 

The Shaffer club-foot shoe is a modification of the Taylor shoe, and 
is shown in Fig. 310. The extension shoe employed by Dr. Shaffer, and 
one which he has more fully developed, is shown in Fig. 31 1 . The claim 
that Dr. Shaffer makes for the apparatus he employs is the ability to over- 
come shortened tissues by means of great force employed by a rack and 
pinion or an endless screw. The treatment is very efficient in his hands. 
I have not employed the apparatus to any great extent, because I have 
found that simpler measures can be used. The Sayre club-foot shoe is 
shown in Fig. 312. Indeed, I might enumerate a large number of 
various forms of the club-foot apparatus, all of which in the hands of 

the inventors certainly accomplish 
F^*J- 311- excellent results. The object, hoAv- 

ever, of the present section on club- 

foot is to set forth in as much de- 

lC!bE3' I *^'' ^^ possible the appliances with 

'■^'^'^ "" "* which I have become familiar, and 

which, to me, seem all-sufficient. 
In omitting, therefore, to describe 

Fig. 312. 





Shaffer's extension equinus brace applied, showing 
action of heel-strap. 

and illustrate the club-foot shoes employed by orthopsedic suro'eons in 
general, as well as the surgeon, I do not wish to criticise. "^ 

Plaster of Paris as a retentive appliance has already been described 
in the equino-varus of infancy. It is used to great advantage in the 
older cases. Indeed, after the deformity is corrected or partiallv cor- 
rected by any of the methods now in vogue there is really no better 
retentive dressing than plaster of Paris. If one is not familiar with all 
the detads of plaster and has had no experience in its application then 
it would be better not to employ this as a retentive dressing, because the 



CLUB-FOOT. 



305 



abuses are numerous. For instance : an excoriation produced in a foot 
whose nutrition is already very poor — and this is more especially true 
of paralytic forms of club-foot — is most difficult to heal. The average 
surgeon knows I'eally very little about the use of plaster. It would 
seem unnecessary to devote any further space to instruction in the use 
of plaster, because nearly all the text-books on surgery have gone so 
fully into this subject. 

With the Wolff method the profession is not so familiar, and hence 
it may not be inappropriate to describe the use which Professor Julius 
Wolff of Berlin makes of plaster in the correction of the deformity of 
club-foot. After quite an extended use of his method I am convinced 
that it can be made serviceable in a large number of obstinate cases. 
The plan is to encase the foot in a snug-fitting plaster-of-Paris bandage 
from the base of the toes to the upper portion of the calf, the foot, of 
course, being brought into the best position possible by manual force 
without an ansesthetic. After twenty-four hours, when the plaster is 
fully set, a wedge-shaped piece is removed from the outer side of the 
foot on a line with the mid-tarsal articulation, the wedge beginning just 
over the head of the astragalus and extending to the middle of the sole 
of the foot. The width of the wedge should be at its greatest portion, 
which is over the cuboid, from a half inch to an inch. The section of 
plaster is to be completed by a simple incision across the inner border 
of the foot, so that there will be a complete solution of 
continuity between the plaster which encircles the front 
of the foot and that which encircles the posterior por- 
tion. Now the surgeon may correct the deformity still 
further by manual force and with very little pain to the 
patient. While the foot is held in this improved posi- 
tion a fresh plaster-of Paris bandage is bound about the 
line of section, and the good position is thus maintained. 
After two or three days the same procedure should be 
followed, and so on until the varus is completely over- 
come. In order to overcome the equinus a wedge- 
shaped portion should occupy the top of the foot over 
the mid-tarsal joint. An illustration of this form is 
shown in Fig. 313. 

Thus much for the treatment by means of apparatus, 
but apparatus must play an important part in the after- 
treatment of nearly all the operations that are employed 
for the relief of club-foot. It is true that the surgeon 
claims to perform operations that will do away with 
the necessity for apparatus of any kind, but, so far as 
my own experience goes, even the most approved opera- 
tions, as a rule, require some sort of mechanical con- 
trivance to maintain the good result obtained. The operations are — (1) 
Manual correction under an ansesthetic ; (2) The employment of me- 
chanical force under an ansesthetic, such as the tarsoclast of Bradford, 
the Thomas wrench, the Phelps machine, etc. etc. ; (3) The subcutaneous 
tenotomy and myotomy, coupled usually with the employment of manual 
or mechanical force ; (4) The open section, with division of all the soft 
parts until with manual force the deformity can be corrected ; (5) The 

Vol. 11—20 




Showing the Wolff 
method. 



306 ORTHOPAEDIC SURGERY. 

bone-operations on the foot, such as removal of the astragalus, cuneiform 
osteotomy, and linear osteotomies. 

The employment of manual, or even mechanical, force under an 
anaesthetic is often justified, and indeed is a very excellent method to 
employ where time is an essential element. In very young infants the 
varus may be completely overcome at a single sitting, and retentive 
appliances can be worn for two or three weeks, while the equinus can be 
very nearly overcome at another sitting, and completed at still a third. 
The simplicity of the tenotomy and myotomy appeal, however, to the 
surgeon, and so much can be accomplished by these procedures that 
manual or mechanical force is usually supplemented by tenotomy or 
myotomy, or both. 

There is a growing disposition among surgeons to make light of sub- 
cutaneous tenotomy and to advocate division of tendons through an open 
wound. Indeed, some surgeons go so far as to relegate subcutaneous 
surgery to the Middle Ages. The chief reason for such a statement is 
that in rare instances aneurysms are reported to have resulted from sub- 
cutaneous tenotomies. The freedom with which sections of various 
tissues can be made under the present aseptic system has led certain 
orthopaedic surgeons to cut recklessly. Now, if an orthopaedic surgeon 
injures a blood-vessel while attempting to divide the tendo Achillis, for 
instance, it is not the fault of the operation, but it is because he has not 
familiarized himself with the simple details of so valuable a procedure, 
or it may be because he has grown reckless or careless by reason of his 
long service ; and certainly this is no excuse for an accident of that 
kind. The rules for dividing tendons are so simple that they ought to 
become familiar to every student. The principal rule is to map out the 
tendon with one's finger, to refresh one's anatomy a little, and then insert 
the tenotome through the skin and behind the tendon. One does not 
need to divide all the tissues in the neighborhood of the tendon. Take 
the peroneal tendons, for instance, or the tendons of the tibialis posticus 
or tight bands of plantar fascia. These can be all sufficiently brought 
out by a little manipulation, so that their division subcutaneously can be 
easily accomplished. Any student, therefore, can be taught to divide a 
tendon subcutaneously with perfect safety, but any student cannot be 
taught to divide a tendon through an open wound and get the result 
which an accomplished surgeon in a well-appointed operating-room can 
in the majority of instances obtain. Another advantage which sub- 
cutaneous tenotomy possesses is that the operation can be done frequently 
without an anaesthetic and in one's office. Indeed, the operation can be 
done almost as soon as suggested. The mother will very often submit to 
a proposition of this kind with infinitely more alacrity than she will to a 
procedure which necessitates the use of ether or chloroform and an open 
wound. One important lesson to learn in any of these subcutaneous 
operations is to over-correct immediately, and not wait for a certain 
number of days to begin the correction of the deformity. A few simple 
details as to dressing may not be inappropriate in this connection, and 
they are as follows : Employ a bit of protective or adhesive strip to 
cover the punctured wound made by the tenotome ; avoid crowding any 
pads or dressing between the ends of the divided tendon, but so adjust 
any aseptic or other dressings that no pressure will come over the skin 



CLUB-FOOT. 307 

■which lies between the ends of the tendon ; take special care to protect 
the instep well, especially where the foot is brought up in sharp dorso- 
flexion, and in this way constriction of the parts will not occur. 

The treatment by open section has received a powerful impetus by 
the labors of Dr. A. M. Phelps of New York. He has sufficiently 
demonstrated that a large section can be made in the sole of the foot 
and through the inner border ; that the deformity can be in this way 
corrected ; that the open space will fill in with blood-clot, which will 
become organized. In cases where tenotomy and myotomy fail, where 
resort to violent force under an anaesthetic fails, the open method offers 
the next step in operative procedures, and will be all that is necessary 
for a large proportion of very obstinate cases. Even this operation is 
occasionally supplemented by removal of bone on the upper and outer 
aspects of the foot. 

This brings us to the question of osteotomy, whether cuneiform or 
linear. The cuneiform osteotomy is an operation that has long prevailed, 
and that will probably remain as a serviceable method in certain obsti- 
nate cases. The special kind of cuneiform osteotomy must largely 
remain a matter of choice with the individual surgeon. That of Davy 
is most commonly employed, and consists of a wedge-shaped section 
through the outer side of the foot, involving the cuboid, part of the 

Fig. 314. 




Club-foot treated by tenotomy and manual force. 

scaphoid, the neck of the astragalus, and portions of the cuneiform 
bones. One who begins an operation with the idea of sacrificing the 
smallest amount of bone-tissues rarely completes the procedure of Davy, 
but finds it possible to correct, and even over-correct, without so much 
loss of bone-substance. A linear osteotomy through the neck of the os 
calcis is sometimes all that is necessary. The removal of the head of the 
astragalus will often enable one, with the section through the soft parts, to 
get all that is desired. An operation which has much to commend it in my 
judgment is removal of the astragalus. After all, one who has had a long 



308 OBTHOPJEDIO SURGERY. 

experience in the management of club-foot finds that these major ope- 
rations are seldom called for, and that he can correct the most obstinate 
cases without resort to such extreme measures. For instance, a case 
represented in Fig. 313 was cured without any bone-operation, but simply 
manual force under an anaesthetic from time to time, a tenotomy or so, 
and the employment of the Wolff method. Take, again, Fig. 314. This 
patient was never subjected to any severe operation, and he was cured 
many years ago. Quite recently I find that he has followed the occupa- 
tion of butcher. 



The Less-febquent Forms of Olub-foot, such as Calcaneus. 
Valgus, Oavus, Pes Planus. 

Calcaneus. 

For calcaneus we rely upon both mechanical and operative measures. 
The aim is to relieve traction on the tendo Achillis. To this end de- 
vices are employed which keep the foot extended. A simple strap of 
webbing from the back of the heel up to a calf-band which partly 
encircles the calf, held in place by a strap, is very simple, and so long 
as the strap is efficient the extended position of the foot can be main- 
tained. The braces employed are such as have a reverse catch at the 
ankle-joint — that is, the ordinary form of club-foot shoe which has 
already been described — with a rivet or peg back of the lower end of 
the upright and just below the joint. Simple as this appears, it must 
really be a very heavy apparatus to meet the indications, because all the 
weight of the body is borne upon the ball of the foot, and this weight 
is transmitted to the shin-bone, upper portion. As a result, the foot- 
plates break very frequently, the peg which makes the reverse catch 
wears ofF soon, and for that reason a more complex joint is required, 
and one, as above stated, quite heavy. Where a shoe is employed and 
where the brace is attached to the shank, a very heavy steel plate needs 
to be inserted in the sole and specially reinforced throughout the shank. 
In very young children, where it is not so important that they should 
walk (and the misfortune of this is that the calcaneus usually occurs 
after the second year of life and as a result of poliomyelitis), plaster of 
Paris or water-glass bandage may be employed. The heel of the shoe 
can be raised quite high and made wedge-shaped, so that the weight will 
be distributed between the ball and the heel. My own experience, I am 
sure, coincides with that of most orthopsedie surgeons, and it is this : 
there is really very little to be expected in the way of cure. The 
apparatus is worn for years usually, and finally the patients get tired 
of it, and prefer to let the shoe get ill-shapen, and wear the heel off as 
they walk. 

The operation that has been most successful in my hands, and that 
is really an old procedure, is the shortening of the tendo Achillis by 
removal of a portion and suturing the tendon, or by an oblique section 
of tendon with free overlapping, the parts held in place by strong 
sutures which are long undergoing absorption, such as silkworm gut, or 
kangaroo tendon preferably. Wire is sometimes used, but this is not a 
very reliable agent, as the irritation that follows from the moving up 



THE LESS-FBEQUENT FORMS OF CLUB-FOOT. 



309 



Fig. 315. 



and down of the tendon causes sometimes suppuration, and finally the 
wire is exfoliated. Many attempts have been made to get a satisfactory 
operation of this kind, but the operation which has yielded me the best 
results is that known as the Willet, after Mr. Willet of St. Barthol- 
omew's Hospital. This consists of a pretty free section of the parts, 
full exposure of the tendo Achillis through a Y-shaped incision, the 
firm suturing of the divided tendon, and secondarily a suture of the 
tendon to the soft parts as well. The whole operation, when completed, 
gives a very strong mass, which, under 
a good deal of after-protection, holds 
fairly well. About 50 per cent, of the 
cases upon which I have operated have 
remained cured after four or five years. 
One of the difficulties is that the calca- 
neus is rarely ever pure and simple, but 
it is associated with a paralysis of the 
peroneals or the posterior tibials, or even 
the anterior tibials, and in addition to 
the calcaneus we have a flail-foot. The 
operation is certainly justifiable, and in 
the hands of one who has had a very 
large experience in work of this kind 
an excellent result may, as a rule, be 
predicted. A very good illustration of 
this deformity may be recognized in 
Fig. 308. The apparatus to be emploj^ed 
after the plaster of Paris is discontinued 
is a rude contrivance, yet serves a very good purpose. A shoe can be 
applied over it, and the principle involved is that we have an unyielding 
tongue to the shoe. The apparatus, with shoe applied, is shown in 
Fig. 315. 

Valgus. 

Talipes valgus is treated best by some form of apparatus, and where 
there is an equinus complicating the tendo Achillis should first be either 
stretched or divided, so that this element of deformity can be eliminated. 
In milder cases of valgus a spring of some kind may be inserted within 
the shoe, such as the Whitman spring for flat-foot, or the shoe itself may 
be built up on a last with high arch and the shank reinforced by steel. 
But, after all, it is necessary in the majority of cases to have a leather 
pad attached to the inner plate of the ordinary ankle-supporter, which 
leather pad shall pass over the inner side of the foot and be secured to 
the bar which passes up on the outer side. In milder cases, too, the 
sole of the shoe may be raised along the inner border from the end of 
the heel to the tip of the toe. Say, have this whole border from a 
quarter to a half inch higher than the border on the outer side. A fair 
illustration of valgus may be seen in Fig. 307. 




Shoe for calcaneus. 



Cavtis. 

In the management of talipes cavus the principles are not very com- 
plex. One needs only to employ a plate on which the foot can be well 



310 obthopjEdic surgery. 

strapped, bringing what pressure can be borne over the instep. In pro- 
portion to the pressure that can be borne, just in that proportion will 
the deformity yield ; but where there are tense bands of plantar fascia 
it is just as well to divide these subcutaneously and at the same time 
break down the high arch under an ancesthetic. The neat-fitting plas- 
ter-of-Paris bandage for two or three weeks after the production of so 
severe a sprain is, as one would suppose, called for. Then an apparatus 
worn for a few months will succeed in effecting a cure. 

Pes Planus, oe Flat-foot. 

This deformity is either atonic or spasmodic. By the term " atonic" 
is meant a flat-foot which is dependent upon weakness of the ankles, 
which weakness has no reference to paralysis, but is simply a lax condition 
without any spasm and occurring in children or in adolescents. The 
atonic may also be due to paralysis from poliomyelitis or from a cerebral 
lesion. The spasmodic form is known usually as painful flat-foot, and is 
associated with more or less spasm of the muscles. This spasm seems to 
be brought about by a dropping of the arch of the foot, due to changes in 
the articular facets of the bones that go to make up the arch of the foot, 
and thus an irritation is produced. We have all grades of flat-foot, 
from a very slight dropping of the arch to a complete dislocation of the 
bones of the mid-tarsal region. The scaphoid may be so prominent 
that the hollow of the foot will really " make a hole in the ground." 
In such cases there is a depression on the outer side. The walking is 
very painful, and there is abduction of the foot, with subluxation for- 
ward and downward of the head of the astragalus. 

Pathology. — The pathology of flat-foot has been so fully presented 
within the last few years that it is needless to discuss the subject at 
length in this connection. 

Diagnosis. — The diagnosis is a very important feature, and one must 
differentiate from tuberculous ankle, severe sprain of long standing with 
periarticular adhesions, and from malignant disease of the ankle. 

The presence of extra heat about one or both of the malleoli, with 
bony enlargement, abduction of the foot, spasm on passive movements, 
and atrophy of the calf, will enable one to diagnosticate a tubercular 
ostitis of the ankle. 

The history of a sprain, with the usual treatment that is customary 
in such cases, with position of the foot, will enable one to make out a 
chronic sprain. 

Malignant disease of the ankle or foot of course is very difficult to 
recognize, and is fortunately so infrequent that a mere mention of this 
disease is sufficient in the way of discussion. 

Treatment. — The treatment of the two kinds of flat foot is — first, 
mechanical; second, operative. 

In mechanical may be included the building up of the soles of shoes 
on the inner side, so as to throw the foot into better position and bring 
the vertical bearing in a line with the tarsus. It may be in the shape 
of springs within the shank of shoes, inserted by the shoemaker. It 
may be a high Spanish last, on which the boot is constructed. It may 
be an apparatus that is attached to the shank of the shoe on the outer 



BHACHITIC DEFORMITIES. 311 

side and extends in a bar to the upper third of the calf, where a band 
secures it to the calf, the depressed arch being supported by a leather 
pad passing from the inner side of the foot over the malleolus and 
fastened to this upright bar on the outer side. All of the devices just 
mentioned have their place in the management of the atonic forms 
of flat-foot, and even in some where there is a moderate degree of 
spasm. 

In the severer forms, however, operative procedures are called for, 
and these include correction of the deformity under an anaesthetic, with 
an attempt to reduce the luxations or subluxations, the various operations 
of the bone, division of the tendo Achillis, etc. From my own obser- 
vation and experience with a very large number of cases of flat-foot 
I am prepared to doubt very seriously the value of any bone-operations. 
Indeed, I do not know of any cures that may be regarded as perma- 
nent or that may be regarded as perfect from these procedures ; while, 
on the other hand, I do know of a large number of cases successfully 
treated by manual replacement under an anaesthetic, supplemented by 
a flat-foot spring. The spring which has been most serviceable in 
my hands is that known as the Whitman spring. Indeed, I cannot 
do better than give an outline of Dr. Whitman's management of a 
case : 

If the deformity can be over-corrected without an anaesthetic, then, 
under manual force, this is done. If this is impossible, under an anaes- 
thetic the foot is converted from a valgus into a varus. The tendo 
Achillis is stretched, so that all the elements which go to make up a 
case of flat-foot are done away with. It is specially important to over- 
correct and to break up the adhesions that may exist. The foot is 
immediately placed in plaster of Paris in this over-corrected position, 
and at the end of a fortnight the plaster is removed, the sprain found 
pretty well under control, and a cast of the foot taken in the best 
position possible for walking. From this cast is made an iron cast on 
which a spring can be hammered out so as to fit the shank of the foot. 
This spring, when completed, has three points of bearing — the outer 
side, the posterior and anterior portions. The inner side is well raised, 
is deeper than the outer side, and furnishes an excellent support for the 
foot. The steel, after it has been properly shaped, is tempered, pol- 
ished, nickel-plated, and finally shellacked. It can be made suitable 
for any shoe and furnishes an adequate means of support. Before this 
is completed the treatment for the foot consists of daily manipulations 
with hof^water douche or hot baths, with an effort on the part of the 
patient to toe in as he walks. Indeed, Dr. Whitman prefers a Wauken- 
fast shoe. As supplemental, exercises may be employed. Massage is 
useful. The aim really is to restore the muscles to their proper tone, 
to make them, by being replaced in normal position, useful in supporting 
the arch, and eventually the spring may be discontinued. 

Rhachitic Deformities. 

Under this heading may be included pigeon-breast, bird's-nest de- 
formity of the thorax, rhachitic kyphosis, knock-knee, bow-legs, antero- 
posterior curvature of the long bones, and weak ankles. 



312 ORTHOPEDIC SURGERY. 

Pigeon-breast. 

Pigeon-breast, known as pectus carinatum, is a deformity that is of 
no very great significance, and is hardly worthy of a place in a text- 
book of surgery. It should be mentioned, however, if for nothing 
more than to impress upon the reader the difficulty of effecting a cure. 
The various devices for correcting a deformity of this kind are usually 
discarded after a little use of the same. The parents, somehow, seem 
to prefer the deformity to the remedy. A truss-spring similar in shape 
to an ordinary truss, with pad in front and over the back, is the most 
common device employed, and in a few instances I have seen the 
deformity undergo a moderate recession. Ordinarily, the mother's 
hand is about the best treatment, and to employ this agent satisfactorily 
the mother should be taught to make firm pressure against the protruding 
chest-walls while the child takes free inspirations. This procedure, 
employed for fifteen or twenty minutes a day, extending over a period 
of two or three months, really alters the shape of the thoracic walls a 
good deal, yet on account of its simplicity it is very difficult to carry out 
any systematic treatment of this kind. 

Bied's-nest Deformity. 

The bird's-nest deformity is a marked depression at the lower end 
of the sternum, resembling a bird's nest, is of very infrequent occur- 
rence, and no satisfactory means have been devised for its correction. 
Indeed, it is of very little significance one way or the other, does not 
interfere with a child's health, and is simply objectionable from a cos- 
metic point of view. 

Rhachitic Kyphosis. 

A general antero-posterior curvature of the spinal column is the 
characteristic feature of rhachitic kyphosis. In the foregoing nothing 
has been said concerning the etiology or pathology of rickets, for the 
reason that a full discussion of the subject is better adapted to a work 
on paediatrics. 

The age at which these changes occur is between the first and third 
year of life. The spinal deformity, however, occurs prior to the first 
year, as a rule. The causes which produce rickets are present at this 
period of life, and the position in which the child is held contributes 
largely to the mechanical production of the deformity. It persists even 
beyond the third year, and is easily recognized by its relationship to 
other rhachitic changes in the body ; for instance, the beading of the 
ribs, the sternal deformities, the epiphyseal enlargements, the abdominal 
appearances, the deformities of the lower extremities. While cases 
of rickets differ according to the severity of the lesion, a reasonably 
careful examination will enable one to differentiate the curvature of 
this disease from that of tuberculous disease of the bodies of the 
vertebrae. A very easy method of making a differential diagnosis is 
this : Place the child in the prone position either across the mother's 
lap or on a table. Grasp the feet and legs with one hand, and with 



THE MORE COMMON RHACHITIC DEFORMITIES. 313 

the other hand over the back as a fulcrum attempt extension of the 
spine. If it be rhachitic, the deformity will disappear, or at least 
so nearly disappear that the flexibility of the column can be easily 
established. If it be the kyphosis of Pott's disease, the deformity 
will not disappear and the spinal column will appear rigid. Again, 
the kyphosis of Pott's disease is, as a rule, sharply angular, while 
that of rickets is more in the nature of a curve, and, indeed, one can 
speak of a posterior curvature of rickets, while the term is not appro- 
priate for the kyphosis of Pott's disease. After all, the diagnosis is the 
chief point of interest in rhachitic kyphosis. 

The treatment is mostly constitutional and positional. It is very 
seldom that apparatus is called for in the correction of this deformity. 
The flexibility of the column itself is sufficient guide in the way of 
treatment, for one can readily see that the upright posture contributes to 
the increase of the deformity, and naturally the recumbent, whether prone 
or supine, will afford relief. The nurse or mother can easily be instructed 
as to the best position in which to place the child throughout the day as 
well as by night. There is nothing better than one's hand or arm on 
which the child can rest, the trunk acting somewhat as a see-saw. It is 
of course not meant that the hand or arm should be continuously em- 
ployed in this way, but a number of times a day for short periods. The 
prone posture, the supine as well, with a pillow on which the back can 
rest, should be maintained at night. 

In cases of congenital rhachitic kyphosis an apparatus of some kind 
is nearly always required — a simple antero-posterior spinal assistant, 
such as the Taylor brace for Pott's disease or the Knight spinal brace. 
Plaster of Paris cannot be made available, because of the peculiar shape 
of the body. The congenital deformities from rickets are so rarely met 
with that detailed accounts of appliances must necessarily prove of little 
avail in discussing mechanical treatment. 

Any system of feeding which is accompanied by signs of rickets 
should, of course, be abandoned, and another system substituted. So 
little attention is given to infant feeding by the family practitioner that 
a child may suffer from rickets for months, and even develop deformity, 
before medical or surgical advice is sought. Psediatric literature is cul- 
tivated to such an extent that it is fair to presume that there will be a 
more general knowledge of the care of infants diff^used into the profes- 
sional mind, and that greater attention will be given to the early stages 
of rickets. 

The More Common Rhachitic Deformities, such as Knock- 
knee, Bow-legs, and Anterior Tibial Curves. 

Knock-knee. 

The term knock-knee has for synonyms Genu valgum, In-knee, Genu 
introrsum. The Germans employ the terra Knickbein, X-bein, etc. etc. 
The names are sufficiently explanatory of the appearance of the defor- 
mity. 

Knock-knee appears about the time that the child begins to walk. 
It is occasionally seen before this period. In adolescence it sometimes 



314 ORTHOPJEDIC 8UROEEY. 

presents, but is not so often of rhachitic origin at this period. There are 
a number of factors which contribute to the production of knock-knee, 
such as bony changes at the articular surfaces, lengthening of ligaments, 
and general lack of muscular tone due to the disease itself. There are 
three bony deformities found in knock-knee, any one of which is suf- 
ficient to produce the deformity : the condyles of the femur differ in 
size ; the articular facets of the tibia are unequal ; the shafts of the 
bones may curve. It is easy to recognize the changes in the condyles by 
flexing the knee sharply and noting the difference in length. An antero- 
lateral curvature of the femora is often associated with the difference in 
length between the condyles, and, indeed, one might depend upon the 
other. There are various grades of this deformity, and one finds the 
text-books fully illustrated. It is sometimes unilateral, or you may 
have knock-knee on one side, bow-leg on the other. For instance, in 
Fig. 316 we find a very good illustration of the two deformities in one 
subject. 

Fig. 316. 




Knock-knee and bow-leg in same subject. 



It is safe to assert that any case of knock-knee can be cured ; it is 
also safe to assert that many cases undergo a spontaneous cure. It is 
exceedingly difficult to obtain statistics bearing upon the spontaneous 
cure of knock-knees, for the reason that the minor grades of the deform- 
ity seldom come under observation at the clinic, and the general practi- 
tioner attaches so little importance to the subject that he is unwilling to 
devote any time to a collection of observations. 

Following Bradford and Lovett, the treatment may be divided 
into three divisions : first, expectant ; second, mechanical ; third, ope- 
rative. 

The expectant treatment is sufficiently safe for the milder cases, for 
the term "expectant" itself presupposes frequent observations, with 



THE MORE COMMON BHACHITIO DEFORMITIES. 



315 



attention to the dietetic details and to hygienic regulations. For instance : 
If a given case come under observation for the first time, one naturally 
looks into the question of diet, into the question of hygiene, and into the 
general condition of the muscles, bones, and ligaments. Tracing may be 
taken or not of the deformity. If it is very slight, of course this is not 
done, but where it is of moderate grade, then it is certainly wise to take a 
tracing of the limbs as they lie naturally on the table or in the best posi- 
tion into which they can be forced. Such a record may easily be kept for 
comparison later on, and after a few months of waiting — expectant treat- 
ment, as we call it^— the physician can easily determine whether to resort 
to mechanical or operative procedures. Children who live in the country, 
and those who have even good hygienic surroundings in cities, are sub- 
jected to the expectant treatment with gratifying results. The main 
difficulty is to overcome the mother's objections to the deformity from a 
cosmetic standpoint. 

The mechanical treatment is called for in cases that fail under the 
expectant plan and in cases where the deformity is very pronounced — a 
deformity which is easily recognized as depending upon bony changes. 
The age for the most efficient mechanical treatment is between the second 
and the fifth years of life. Beyond the fifth, in my experience, mechan- 
ical treatment accomplishes very little. The bones have become so hard 
that it is difficult to make any impression upon the elongated internal 
condyle, and if enough force is employed the patient complains so much 
that the parents become very lax in attendance. My own plan is to 
advise against mechanical treatment, as a rule. Devices such as building 
up the shoe on the inner side, so as to throw the weight toward the outer 
border of the foot, sleeping at night with pads between the knees, feet 



Fig. 317. 



Fig. 318. 





Mikulicz's plaster bandage 
(Sehrelber). 



Vogt's plaster bandage with elastic 
traction (Scbreiber). 



bound together, keeping the child off the feet as much as possible, serve 
me a very good purpose. 

If one decides to employ apparatus and can overcome the objections 
on the part of the parents to confinement to bed or a wheeled chair. 



316 



ORTHOPEDIC SURGERY. 



almost any form of apparatus will be serviceable, provided sufficient 
care is given to the application of the same. Any appliance which 
allows motion at the knee is not so efficient as that which is employed 
without motion. The child can very easily walk with the knees held im- 
mobile, and will soon acquire proficiency in walking. Plaster of Paris 
may, therefore, be employed. The limb can be forced into a very good 
position without an anaesthetic, plaster can be applied, and within a fort- 
night the procedure can be repeated. The plaster dressing employed 
by Mikulicz is very efficient. This is shown in Fig. 31 7. The elastic 
traction may also be employed in conjunction with plaster, after the 
method of Vogt, as in Fig. 318. The most common form of appa- 
ratus furnished by the shops is that shown in Fig. 319. In ordering 
apparatus of any kind it is well that the surgeon should take his own 
tracing of the limbs — mark on the tracing where he desires the pads, the 
thigh- and calf-bands, and especially the joints. The Shaffer knock- 
knee splint is worthy of commendation, inasmuch as it can be worn 
while the patient is going about, but on account of its expense and the 
difficulty of adjusting it properly it is not generally employed. This is 
shown in Fig. 320. 



Fig. 319. 



Fig. 320. 





Apparatus for knock-knee (Eriehsen). 

After the expectant treatment fails, and after a sufficient trial has been 
given to mechanical appliances, it is not difficult to get consent for an 
operation. In dispensary or hospital practice, however, operations are 
more frequently resorted to, because of the difficulty of getting appa- 
ratus in the first place, and any hearty co-operation after the apparatus 
has been obtained. For this reason operations are performed much 
earlier among the poorer classes. The indications for operation, then, 
may be summed up as follows : the age of the child, between six and 
ten_ years; the high degree of deformity; the extensive osseous changes 
which have produced the deformity ; the failure of apparatus to afford 



THE MORE COMMON RHACHITIC DEFORMITIES. 



317 



any relief. The operations themselves are, in the order of simplicity, 
manual correction under an anaesthetic — most extensively used by Delore, 
the French surgeon — the subcutaneous division of ligaments and tendons, 
osteotomy. 

The manual correction is applicable to a very large number of cases, 
especially in children under six years of age. Beyond this age, however, it 
is difficult to accomplish much by any amount of manual force employed. 
The osteoclast may be employed, and parts may be sufficiently stretched 
with the instrument. A fracture produced by the osteoclast is about 
as easily healed as a severe sprain of the joint, and for this reason the 
instrument is rarely employed unless an osteotomy is desired. After 
correction a strong splint may be employed, or, better still, plaster of 
Paris. At the end of two weeks the plaster should be removed, still 
further correction made, if necessary, without an ansesthetic, and the 

Fig. 322. 



Fig. 321. 




u 



Lines of osteotomy : 1 , Mayer, Billroth, Schede ; Macewen's osteotomes. 

2, Annandale ; S, Ogston, Reeves, Chiene ; 4, 
Macewen ; 5, Taylor. 

plaster reapplied. It is necessary to employ some mechanical support, 
after plaster has been discarded, for two or three months. 

If recourse is had to the knife — and the knife is frequently employed 
even in effiDrts at manual correction — it is necessary only to define the 
tendons or ligaments which are placed on stretch, and this can be easily 
done by the index finger; then thrust the tenotome directly upon the 
tense structures, nick back and forth, and increase the manual force. 
The open section of tendons or ligaments about the knee-joint is not 
advocated, even by the bolder surgeons. 



318 ORTHOPEDIC SUROEBY. 

Osteotomy is the operation par excellence for the older cases, and, 
without entering into details of the various osteotomies which have been 
advocated and from time to time abandoned, the operation of Macewen 
is the one that is most generally employed at the present day. A very 
good illustration of the lines of osteotomy is shown in Fig. 321. Mae- 
ewen's osteotomes are shown in Fig. 322. Several years ago I abandoned 
the open method for Macewen's osteotomy, and have resorted to subcu- 
taneous osteotomy by means of the Vance osteotome, which is similar to 
Macewen's, except that it is not so thick, has a sharp cutting edge, and 
is rounded off at the corners very slightly. With this instrument I am 
enabled to reach the bone without the employment of a scalpel, and can 
easily make section of the bone within a few minutes. The line of 
osteotomy is well known to be about a half inch above the condyle. 
The operation is done, of course, with antiseptic precautions. Care is 
taken to divide the bone at least through two-thirds of its thickness, 
after which the solution of continuity can be completed by manual force. 
The instrument is withdrawn before the effort at correction is attempted, 
a compress placed over the small wound, and healing of the superficial 
parts promptly takes place. In place of inserting the instrument on the 
inner side of the femur, as does Macewen, I resort to McCormick's 
modification, which is to insert on the outer side. This gives the ad- 
vantage of making a kind of hinge of the inner structures of the bone 
and effecting complete solution of continuity. It is well to over-correct 
and put the limb up in plaster from the free ribs down to the ball of the 
foot. In order to make the plaster lighter and ensure better fixation, I 
shape one or two bars of steel to the corrected position of the limb, and 
incorporate this steel within the folds of the plaster. Union takes place, 
as a rule, within four weeks, at the end of which time the plaster can be 
changed. At this period, too, a little better correction can be made if it 
is found desirable. Three or four* weeks' longer use of plaster is suf- 
ficient to complete the cure. The convalescing treatment may be a light 
spring attached to the heel of the shoe and extending up to a pad on the 
outer side of the thigh. Indeed, the knock -knee spring of Hugh Owen 
Thomas is a very convenient convalescing brace. This consists of a 
stem of iron or steel which extends along the outer side of the limb, 
from a crucial-shaped pad at the upper third of the thigh, down to the 
front of the heel, where it is curved into the shape of a small rod, Avhich 
passes through a hole in the heel extending to the inner side. A pos- 
terior bar from the popliteal space to the lower portion of the calf is 
joined to the side-bar by means of cross-bands at either end. This 
posterior portion is merely to keep the appliance in place. A roller 
bandage to hold the limb over to the outer bar completes the 
dressing. 

The knock-knee of adolescence is usually of rhachitic origin. Baker's 
knock-knee is not rhachitic, but depends upon the peculiar position in 
which the patient is obliged to stand a certain number of hours a day. 
The treatment is confinement to bed with side splints, and subsequently 
a walking apparatus. By some the treatment is regarded as exceedingly 
unsatisfactory, but, as far as my own observation goes, a few weeks in 
bed with rest to the parts accomplishes a great deal in the way of relief 
and makes the convalescing treatment very simple. 



the more common rhaohitig deformities. 319 

Bow-legs and Anteeioe Tibial Curves. 

The etiology and pathology of bow-legs are practically the same as 
those of knock-knee. I shall proceed, therefore, to the treatment, which 
is governed by the same general 
principles as that of knock-knee. 
First, we have the expectant, which 
is sufficient for a large number of 
cases ; the mechanical ; and the ope- 
rative. 

Fig. 323. 



Fig. 324. 





Knight bow-leg springs. 



Apparatus for bow-legs (Bradford 
and Lovatt). 



There are mild cases which require practically no treatment and which 
correct themselves. One hardly expects a case to correct itself, for the 



Fig. 325. 



Fig. 326. 




Eubber bandage for bow-legs 
(Davis). 



Grattan's osteoclast. 



320 



ORTHOPEDIC SURGERY. 



reason that the curve is rather low in the tibia and requires an osteotomy 
for its correction. A reference to the remarks on the expectant treats 
ment of knock-knee will enable one to judge equally well about the 
indications in bow-legs. 

A very fair illustration of a pair of bow-leg springs is shown in 
Fig. 323. The apparatus here presented is known as the Knight 
bow-leg spring, and differs in some unessential details from the ordi- 
nary springs of the shops. All are intended to make pressure 
against the convex side of the limb from a bar passing up the 
inner side. In Fig. 323 there is a heel-cup and foot-plate, and a 
free joint at the ankle. The inner bar extends from the joint on the 
inner side to a pad just over the condyle. The outer bar extends from 
the ankle-joint to a calf-band. This outer bar is scarcely necessary, but 
is used in the Knight spring to assist in keeping the apparatus in' place. 
Where the curve is general and extends through the entire length of the 
limb there is usually little need to have any apparatus ; yet where the 

deformity is evidently increasing an 
appliance such as is shown in Fig. 324 
will answer the purpose. -Young has 
presented a very ingenious ^mode of 
employing the rubber bandage, which 
for patients in the recumbent posture 
might prove of great service. This is 
shown in Fig. 325. 

The operative treatment is manual 
force, which may produce a green-stick 
fracture of the limb or even a fracture 

Fio. 328. 



Fig. 327. 





Case of bow-legs. Bow-leg from loss of tibia. 

of the bone. The ostepclast is employed by a certain number of ortho- 
paedic surgeons, yet the general surgeon prefers a simple osteotome. A 



THE MORE COMMON RHACHITIG DEFORMITIES. 321 

fair sample of the osteoclast is shown in Fig. 326, and is known as the 
Grattan osteoclast. I must confess that I have never been enamored of 
the osteoclast, as I have always been able to effect a fracture by manual 
force or a correction of the deformity by a subcutaneous osteotomy. 

Not wishing to present cases, as most of the works are replete 
with illustrations of cures by osteotomy, I will omit illustrations show- 
ing the deformity as well as the result. Fig. 327 presents a most extra- 
ordinary case of bow-legs, due to faulty articulations at the knee. The 
child presented congenital absence of the radius on both sides. In this 
instance I did a cuneiform osteotomy below the epiphyseal line, not 
making a complete solution of continuity of the bone. The result was 
about perfect. 

In Fig. 328 we have a case of bow-leg due to destruction of the tibia. 
This child suffered in early life from necrosis of the tibia. In the efforts 
at removing the sequestrum the lower portion of the bone was destroyed, 
and, as she began walking, there resulted, naturally, a most extraordi- 
nary degree of bow-leg. Dr. William T. Bull did a very satisfactory 
operation by uniting the fibula with the upper end of the tibia. The 
result is shown in Fig. 329. 

The concluding remarks on bow-legs may be summed up as follows : 
Milder cases require neither mechanical nor operative treatment. Even 

Fig. 329. 




Besult In Fig. 328. 



exaggerated cases, where the curve involves the whole length of the limb 
and where there is spraddling, so to speak, do not require treatment. 
Children under four years of age presenting even a marked degree of bow- 
legs may be completely relieved by the use of apparatus. Eepeated 
Vol. II.— 21 



322 ORTHOPEDIC SURGERY. 

attempts at correction with manual force, supplemented with plaster of 
Paris, are sufficient to cure a large number of cases. Osteotomy is pref- 
erable to osteoclasis if the osteotomy be subcutaneous. Cases where there 
is an anterior curve of the tibia require, in rare instances, a cuneiform 
osteotomy. Cuneiform osteotomy should be reserved for a high degree 
of anterior curvature of the tibia, but never used for bow-legs. An excep- 
tion may be made to this rule where the articular surfaces of the joint 
are defective, and then one must depend upon his individual surgical 
judgment. 

Paealttic Defobmities. 

Under this heading may be included many forms of club-foot depend- 
ing upon cerebral or spinal paralysis, deformities at the various joints 
depending upon muscular shortening or muscular spasm, and subluxa- 
tions and luxations of the joints. 

The most common form of paralysis from which deformities result 
is that due to poliomyelitis of infancy. Cerebral paralysis produces 
usually one deformity of the foot — namely, an equinus; and one of 
the hand — a contraction of the fingers. Peripheral paralysis is seldom 
. followed by any extensive deformity, and will be considered in this con- 
nection only as one of the causes of a deformity for which poliomyelitis 
is most frequently responsible. 

The general practitioner and the neurologist have come to the con- 
clusion that little in the way of restoration of a muscle palsied from 
poliomyelitis after a certain period, say one year, can be accomplished 
by electricity or massage, or both. Attention is given much more 
generally now to the deformities which result. It is the province of 
the orthopaedic surgeon to prevent these deformities, and certainly his 
opportunity is better now than it was in former years. It is not in- 
tended to discriminate against electrical treatment, but it is a fact that 
electrical treatment can be carried on to much better advantage where 
joint-strain is prevented by mechanical means. 

There is really nothing complicated about the mechanical support 
for these paralytic limbs. If we have a drop-foot to deal with, an appa- 
ratus which will hold the foot at a right angle with the leg will rest the 
anterior tibial group. If both anterior and posterior tibial groups are 
palsied, then there needs to be a limited joint — that is, a foot-plate set at 
a right angle with the upright and arranged so that a very small arc of 
motion will be permitted. This appliance, for the poor, ought to be 
inside of the shoe. For the better class of patients it can be attached to 
the shank of the shoe and an extra steel spring carried throughout the 
sole. If the quadriceps femoris be paralyzed, then the appliance should 
extend above the knee — say, to the upper third of the thigh. A spring 
joint can be applied at the knee, so that when the patient assumes tlie 
upright position the flexed leg will extend and by its own weight lock 
the joint at the knee. If the patient wishes to sit down, he can touch a 
spring or slip up a peg of some kind, which will liberate the lock-joint 
and flexion can occur. These appliances are so very common that it is 
hardly worth while to illustrate. The cheaper forms of apparatus are 
those which do not permit of any motion at the knee. The limb is 
simply bound to the uprights and a peg-leg is made of the limb. For 



PARALYTIC DEFORMITIES. 323 

young children a joint is entirely unnecessary, and, indeed, is rather a 
disadvantage, for the joint-ligaments are strained a good deal by the 
movement and the muscles which need protection are not so well pro- 

FiG. 330. 



Paralysis from poliomyelitis. 



tected. There need be no fear of ankylosis or stiffness of the limb from 
prolonged immobility. The joint can be moved a little night and 



Fig. 331. 




Extreme deformity in paralysis. 



morning, and all dread or fear of ankylosis can be thus dispelled. For 
charity cases a joint is not employed under ten years of age. Where 



324 



OBTHOPJEDIC SUBGEBY. 



the thigh flexors are involved or where the gluteal group of muscles are 
palsied, so that the head of the bone is not held securely in the acetab- 
ulum, a pelvic band is attached to the upright support, and with 
such an apparatus the patient is able to get about with a fair degree 
of facility. It is employed extensively at the Hospital for the 

Euptured and Crippled. It is, of course, 
Fig- 332. applied after all deformity is corrected- 

The case is usually one of dangle-leg, 
and with the appliance the patient can 
get about very often without the aid 
of a crutch. As the patient grows 
older it becomes a very serious question 
whether the apparatus should not give 
way to an excision of the joints for 
the purpose of producing synostosis. 
It is astonishing how lax the joints 
may become after a poliomyelitis, and 
a very good illustration is shown in 
Fig. 330. A case like this requires ap- 
paratus on both sides, with pelvic band. 
Crutches are needed as well. 

The operative treatment consists of 
subcutaneous division of tendons and 
muscles, division of the same by open 
section, manual force under ether, with 
the immediate application of plaster 
of Paris to maintain the good position. 
The plaster gives way after a few weeks 
to some form of support. It is possible 
to divide the tendons about the foot, the 
hamstring tendons, the tensor vaginae 
femoris, the adductors of the thigh, and 
even the fascia lata — all subcutaneously. 
Where these simple procedures fail, it is 
very easy then to make open section and divide muscles, tendons, and 
fascia as they present under the finger. A very interesting case of 
deformity is shown in Fig. 331. This boy was known in the hospital 
as the "Kangaroo Case." The figure shows his mode of locomotion. 
It was simply impossible for him to extend his thighs, the flexors at 
the hip were so very short. Under ether an open incision was made 
and all the muscles down to the capsular ligament were divided ; that 
is, all muscles which presented any resistance to extension. Within a 
few weeks he was walking on crutches and apparatus, no longer quadri- 
pedial. He has attended school for the past three or four years. 1 have 
recently had him photographed, and the result is shown in Fig. 332. He 
still presents a little deformity at the hips, but is able to stand with 
very little assistance, without apparatus of any kind, but with the appa- 
ratus he goes about and attends as an out-patient. 

The operation of arthrodesis, which is an effort to secure ankylosis 
at a joint, is often indicated, especially where it is difficult to keep appa- 
ratus in repair and where the patient is unable to bear the expense 




After section of muscles. 



DISEASES OF THE JOINTS 325 

At the ankle-joint the articular surfaces can be easily reached and pared 
off, and union should take place without any suppuration. The same is 
true of the knee-joint. The operation is seldom called for at the hip. 
Where this seems a necessity it would be better to amputate. 

Diseases of the Joints. 

General Considerations. 

It is generally conceded that American surgeons have made the 
greatest advance in the treatment of not only the diseases which im- 
plicate the joints, but of the deformities which result from these dis- 
eases. It is therefore fitting that a treatise on orthopaedic surgery 
should include both acute and chronic diseases of the major, as well 
as the minor, articulations. As already outlined in the earlier part of 
this dissertation on orthopsedic surgery, the prevention as well as the 
•correction of deformity demands most careful consideration. In dis- 
cussing the joints it is unnecessary to divide the subject into diiferent 
parts corresponding to the joints involved, except in so far as treatment 
is concerned. In a general way we can treat of the etiology and the 
pathology. 

Nomenclature. — The role which tuberculosis plays in the etiology 
and pathology of the diseases now under discussion enables us to name 
two general divisions — tubercular and non-tubercular. Then, again, we 
have acute and chronic — the acute rarely tubercular, the chronic, as a 
rule, tubercular. The above statement must be taken in the light of a 
marked difference between the chronic joint disease of children and of 
adults. For instance : the majority of cases of such disease in children 
are tubercular, while in adults the non-tubercular diseases predominate. 
The division, anatomically speaking, is the following : Periarthritis, 
arthritis, synovitis, articular ostitis, osteo-arthritis. It is admissible to 
name a disease after the joint involved — for instance, shoulder disease, 
hip disease, knee-joint disease, etc. — yet a nomenclature of this kind is 
misleading. It is not sufficiently scientific, for the reason that accurate 
•diagnoses are seldom required and the therapeutics must, of necessity, 
be unsatisfactory. The term "traumatic" as applied to joint diseases 
is not so generally employed as it was one or two decades ago. 

Taking up the different joints, we have in common use the following 
nomenclature : 

For the joints of the upper extremity : 

Periarthritis, arthritis, tubercular ostitis. 

In the lower extremity : 

For the hip : Hip disease — a very common term — -hip-joint disease, 
morbus coxarius, coxitis, tuberculosis of the hip, articular ostitis of the 
hip, periarthritis, rarely synovitis, bursitis, neurosis. 

For the knee : Periarthritis, acute synovitis, chronic synovitis, 
hydrops articuli, hydrarthrosis, tumor albus (white swelling), arthritis, 
osteo-arthritis, internal derangement of, bursitis of the knee, neurosis, 
Charcot's knee. 

For the ankle : Periarthritis, arthritis, tubercular ostitis, white swell- 
ing of, caries of, neurosis of. 



326 obthopjEDic surgery. 

Etiology. — Acute joint diseases are, as a rule, traumatic. Excep- 
tionally, we have the idiopathic disease depending on a germ of some 
kind. The chronic affections of the joint depend, in children, primarily 
upon the bacillus of tuberculosis. In adults they result from a sprain 
of some kind ; that is, trauma, from rheumatism or gout, and from cer- 
tain lesions of the nervous system. It is unnecessary to dwell in detail 
upon the mode of invasion of the bacillus of tuberculosis. It is simply 
enough to say that the germ is introduced into the system, that it finds 
its way to the bone-ends, and there develops an ostitis from which an 
arthritis may result. It is conceded that in a number of chronic joint 
diseases in children, tubercular in nature, a slight trauma of some kind 
has served to make active the tubercular focus, and in tliis way contribute 
to the development of a typical tubercular ostitis of the joint. 

Pathology. — A joint that is primarily involved in disease shows 
changes in the articular cartilages, and about the same time in the syno- 
vial membrane. When trauma is the cause the changes may be at iirst 
quite well marked or scarcely significant, yet the use of the joint before 
Nature has had an opportunity of repairing the mischief done tends to 
an increase of the hyperemia and the destructive changes which follow 
an inflammatory process. The deeper structures are involved second- 
arily in such cases, while a very marked lesion may be in progress 
within the joint itself. For instance : one may have a gelatinous con- 
dition of the synovial membrane of the knee, distinctively tubercular, 
while the deeper layers of the cartilage may be scarcely involved at all. 
Where the disease is primarily ostitic the joint-changes are then second- 
ary, and extensive lesions may exist in the bone-ends, while very slight 
inflammatory changes may exist in tlie joint itself. Indeed, joint-changes 
may undergo complete resolution, and a focus of disease in the bone — a 
cavity, for instance — may exist for many years. Bone tuberculosis is so 
intimately associated with the chronic joint diseases of children that we 
can seldom disassociate the two. In adults other changes, such as a 
fibrillation of the synovial fluid, are characteristic of rheumatic aflFections. 
The most important changes that take place, and changes which call for 
the services of the surgeon most frequently, are subluxations, luxations, 
and the usual adhesions which belong to ankylosis. 

Treatment. — This can be discussed only in a general way. The 
principles which underlie the management of diseases of the joints are 
rest and protection. As supplementary — and, indeed, one might say com- 
plementary — to those two principles we have diet, hygiene, and every- 
thing which tends to build up and restore the general health. Details as 
to how rest and protection shall be secured, the time Aviien these princi- 
ples shall be discarded, the necessity for motion, for instance, and use, 
more properly belong to the individual joints now to be considered. 

Ostitis of the Hip. 

Clinical History. — The disease first makes its appearance in the shape 
of slight stiffness at the hip, with a little lameness, scarcely appreciable. 
The pain is usually an early symptom, and this is referred to the knee 
as well as to the hip. Indeed, the pain in the knee so often precedes the 
pain in the hip that one is deceived, and very often mistakes the knee- 



OSTITIS OF THE HIP. 327 

pain for disease at this articulation. The story which parents bring is 
about as follows : The child had a fall, usually a very insignificant fall, 
and afterward began to show a little lameness, stiffness about the hip, 
would fall easily, cry if handled at all roughly, etc. etc. A little cross- 
examination brings out a long interval usually between the fall and the 
first symptoms which the mother can recall. By " long " is meant from 
one to six or twelve months. Indeed, it is learned that the fall is an 
after-thought, and that it requires some little investigation on the part 
of the family to learn about the fall. The symptoms are so very slight 
at first that it is not thought necessary to call for any medical advice, and 
within a few days or a week the little patient is much better. Indeed, the 
parents believe that there is no limp whatever. The rule, however, is a 
limp always, and there are very few cases on record where there has been 
any positive evidence as to the complete disappearance of the limp. 
After the subsidence, more or less complete, of this group of symptoms, 
which we are in the habit of terming an exacerbation, there comes a re- 
mission, which extends over a variable period — from one or two weeks 
to two or three months. The second exacerbation depends usually upon 
some slight trauma. The child, by reason of its awkwardness and the 
cai-e necessary to avoid any distress, gets a fall or a bruise of some kind, 
and there is a repetition of the first train of symptoms. Usually these 
are a little more exaggerated. The lameness is more pronounced. At 
the first attack there may not have been any night-cries. During the 
second one night-cries come on, as a rule, and are very characteristic. 
They are not continuous through the night, but the mother hears a shriek 
or a scream, goes to the little fellow's bed and finds him sound asleep, 
or sometimes finds him with the thigh flexed on the abdomen and hold- 
ing the knee with his hands, still dozing off to sleep. If she watches a 
while by the bed, she observes some spasm of the limb, some grimaces 
of the face, a scream in the sleep. When the muscular spasms become 
severe, the child awakes and will cry for a little while. Intelligent 
mothers sometimes make this observation — that if the limb be held and 
slight traction made the child will go off to sleep, and sleep well as long 
as the traction is continued. After one or two weeks, or a little longer 
perhaps, the symptoms just described subside in a measure, and there are 
less pain and less discomfort, but the lameness then seems to be perma- 
nent. Everyone is convinced that the child is actually lame. The family 
physician is usually consulted about this time, and if he be a careful man 
and has acquired the habit of going over his cases with the thoroughness 
that is requisite, he finds considerable impairment of motion — tenderness 
in making these movements. There are no swelling and no deformity. 
The family history is usually obtained. The child is generally quite 
robust-looking, and the customary opinion given is that it would be 
well to await further developments — that it is difficult to determine 
the nature of the trouble. The second remission is followed by 
another exacerbation, and the examination made usually results in a 
diagnosis. 

While the above is representative of a typical case, there are many 
atypical instances of hip disease. For instance : The first group of 
symptoms may be very slight, very insignificant, and the first remission 
may last from six months to a year, with scarcely any changes during the 



328 ORTHOPEDIC SURGERY. 

remission. Whatever symptoms develop can scarcely be dignified with 
the name of an exacerbation. Again, the invasion may be very sudden, 
very acute, and deformity may result within a few days — a deformity 
which is characteristic of the advanced stage. This exacerbation may 
last for many weeks, or months even, during which time the child is con- 
fined to bed or hobbles about on a crutch, or, if he walks at all, walks 
with great lameness. The subsequent exacerbations are usually not so 
acute. 

The disease, it must be noted, is characterized by exacerbations with 
remissions, and by certain stages which have long been recognized and 
are named first, second, and third. 

The first stage corresponds to the early invasion, and is marked by 
the symptoms which have been described in the early part of this sec- 
tion, marked by the absence of deformity and with a very slight limp. 

The second stage begins with the occurrence of deformity, and is 
marked pathologically by certain changes in the bone-substance itself. 
The structures about the hip have become shortened a little, so that it is 
difficult to correct the deformity even by manual force. During this 
stage abscess appears, and the pressure of the sac upon the soft tissues 
contributes a good deal to the deformity and causes pain of a different 
character from that in the early stage. The limb is much more sen- 
sitive. The deformity is usually an expression of the severity of the case. 

The third stage is marked by the beginning of shortening of the limb. 
Changes now take place in the relationship which the neck sustains to 
the shaft. In place of the normal obtuse angle the angle becomes very 
nearly a right angle. This is thought to be due to muscular spasm, on 
the one hand, and walking on the limb, whereby the weight is thrown 
against the impaired head and neck, thus giving prominence to the tro- 
chanter major. We have then a deformity at the hip which is sometimes 
regarded as a dislocation, because the trochanter is so prominent and 
because it comes above N6laton's line. N6laton's line, it must be under- 
stood, is a line drawn from the tip of the anterior superior spinous 
processes to the tuber ischii. 

The third stage, then, is the stage of shortening ; the second, of slight 
deformity ; the first, of no deformity. The clinical history of the second 
stage is that of very sharp exacerbations, long continued, attended with 
abscess, which occasionally disappears — usually goes on to open spon- 
taneously. When the abscess does open, the hectic fever ensues, the gen- 
eral nutrition is much impaired, the child suffers from loss of sleep, and 
the case may be severe or mild in proportion to the extent of the original 
lesion. This is the stage of crutches, of wheeled chairs, of confinement 
to bed. The third stage is very similar to the second in its history, but 
may include reparative process as well as destructive. If the former, 
the child gets about without crutches or support of any kind, but still 
has a very pronounced limp and the shortening is very marked. If the 
latter, there is a long period of confinement to bed, progressive emacia- 
tion, development of amyloid changes in the liver and kidney, attended 
with albuminuria, urine with low specific gravity, oedema, anasarca, and 
death. A fatal issue may ensue without involvement of the liver and 
kidneys, and the child may simply waste away and die of exhaustion. 

It should also be noted that the second and third stages are not 



OSTITIS OF THE HIP. 



329 



Fig. 333. 



always of the typical form, and are not as above described, 
the second stage may present a very slight 
amount of deformity, and may not pre- 
sent any abscess whatever. The third 
stage may present the usual shortening 
which characterizes the stage, and yet no 
abscess be present. Roughly speaking, 
abscess appears only in about 50 per cent, 
of the cases, and if appropriate treatment 
be early employed 80 per cent, may escape 
abscess, The abscess itself usually results 
in a sinus, and the limb will be marked by 
sinuses, ultimately by cicatrices where a 
favorable issue takes place. 

It is difficult to illustrate by photographs 
the different positions which the hip assumes 
during the course of the disease. The 
changes in the first stage are usually about 
the nates, and it requires very close photogra- 
phy to bring out the slight variations from 
the normal. The second stage is very well 
illustrated in Fig. 333. The third stage is 
more easily illustrated. For instance, in 
Fig. 334 we have the third stage, which 
shows the deformity in flexion, and this 
flexion can be best made out by so placing 
the patient on a table that every one of the 
spinous processes will come in contact with 
said table. In Fig. 335 the same patient 
is standing, and shows the lordosis. Again 
in Fig. 336 we have the third stage well 
illustrated, and the cicatrices are shown as 
well. In addition to this, there is extreme 
equinus, which has resulted by reason of 
the patient's efforts to walk. A very 'good 
illustration of abscess is furnished in Fig, 



Indeed, 




Position assumed In standing, with 
slight abduction of right leg (Brad- 
ford and Lovett). 



337. This occupies a very 



Fig. 334. 




Deformity of third stage. 



favorite site. Deep femoral abscess is, fortunately, uncommon, since it 
is exceedingly difficult to manage, for the reason that it encroaches upon 



330 



ORTHOPEDIC SURGERY. 



the femoral vessels and interferes with operative treatment as well as 

the expectant. 
Pjij 33g Diagnosis. — It is exceedingly im- 

portant to recognize the deformity in its 
early stage. In order to do this a very 
intimate knowledge of the clinical his- 
tory and nature of the disease is essen- 
tial. While every one cannot possess 
the information by clinical experience, 
every one can acquire a routine habit of 
making his examinations, and can culti- 
vate a power of observation which all 
medical colleges should teach. 

Fig. 336. 




Third stage. 



Third stage after abscess. 



There are certain signs which are regarded as pathognomonic, and 
these are few, while there are many other signs and symptoms which, 
taken collectively, go to make up a case, and a knowledge of which will 
enable one to make a diagnosis before any deformity arises. The path- 
ognomonic signs are resistance to movement in all directions — ^this resist- 
ance accompanied with reflex spasm — and a characteristic limp. The 
ordinary symptoms are — changes in nates, flattening, for instance, of the 
same ; loss or shortening of the ilio-femoral crease, atrophy of the limb, 
periarticular tenderness, night-cries, the typical scream, a history of an 
insidious invasion, and persistence in the limp. 



OSTITIS OF THE HIP. 331 

To make a diagnosis, therefore, one should strip the patient, and while 
this is being done a history can be obtained. Then note the comparative 
measurements of the limb. Test the joint-functions, flexion and exten- 

FiG. 337. 




A hip-abscess (Lovett). (By permission of the Trustees of the Fiske Prize Fund.) 



sion, abduction, adduction, rotation inward and outward. These tests 
should be made carefully and deliberately. The sound hip should be put 
through all the movements that we attempt on the affected side. The 
child's expression should be noted when the affected hip is examined. 
In this way one can best discover the reflex spasm which is almost 
pathognomonic. It is not enough to move the limb over a small arc, 
but complete flexion should be attempted, complete extension, and com- 
plete ab- and ac^duction. It happens very often that the reflex spasm is 
not excited until the limits of these movements are reached. Joint-ten- 
derness is seldom present in the early stage — indeed, it is the exception 
to find it present— and in testing for joint-tenderness one should not 
strike the knee or the foot with a blow, aiming thereby to drive the head 
of the bone into the acetabulum, because the child involuntarily resists, 
and, while one may get pain, it is the pain of movement and not of the 
direct blow. Atrophy is mentioned, because this is a very common sign 
in all the varieties and stages of hip disease. It is not dependent upon 
constriction of the limb, but upon the involvement of the nerves impli- 
cated in the disease itself. The nutrition suffers. It is difficult to learn 
anything by palpation, although it is necessary to employ this means of 
diagnosis in one's routine method. 

In the more advanced stages, second and third, diagnosis is not so 
difficult, and we make our examinations usually to determine how much 



332 ORTHOPEDIC SURGERY. 

disease exists, whether the bony changes are very pronounced or not, 
whether the acetabulum is involved, what complications rnay exist, etc. 
etc. ; and in this connection it may be well to state that it is next to im- 
possible, in my own experience, to differentiate between the femoral and 
acetabular form in the early stage. Indeed, it is difficult enough in the 
advanced stages. If an abscess appears above Poupart's ligament, the 
presumption is that the acetabulum has been perforated, and in this way 
the acetabular form can be recognized. But there are abscesses which begin 
at first below Poupart's ligament, and burrow up, to appear in a place 
which would indicate the existence of the perforation of the acetabulum. 
The ordinary gluteal abscess comes from the digital fossa, and appears 
first as a small round tumor just above the trochanter major. Indeed, 
this abscess is sometimes mistaken for the head of the femur, and 
diagnoses of dislocation are often made when this small abscess is pres- 
ent. Palpation in the examination of advanced cases is therefore of 
great service. In making a diagnosis of amyloid disease we should find 
a low specific gravity in the urinary examination, albumin, and casts. 
Amyloid changes may be predicted by a low specific gravity of urine 
without the presence of albumin. The presence of pain in the hepatic 
region has often been noted by myself in observing cases from time to 
time, and I have come to look upon this as an important sign in diagnosis. 

In making a differential diagnosis in the first and second stages we 
have to consider synovitis of the hip, periarthritis, phlegmonous inflam- 
mations within the pelvis and in the ilio-costal space, Pott's disease of the 
spine, hysteria (neurosis of the hip), poliomyelitis, and malignant disease. 

The typical primary synovitis of the hip is so exceedingly rare that 
one seldom encounters this condition from which to differentiate. Many 
years ago I published a few cases of synovitis, but for ten or fifteen years 
I have not observed a single instance. We have an acute invasion, 
dependent upon trauma or exposure to severe cold, early deformity, in 
the first few days pain only of moderate degree, and a distinct fulness, 
which can be recognized deep under the gluteal muscles. 

Periarthritis in children is usually phlegmonous in type — is attended 
with induration, rise of temperature, early disability, absence of reflex 
spasm, and absence of atrophy. The process may be acute or subacute. 
It is rarely chronic. Within a few weeks an abscess may form, the con- 
stitutional symptoms will be very severe, and, when the pus is liberated 
either by nature or the knife, a prompt recovery follows. In the rheu- 
matic form of periarthritis the type is usually chronic. There is very 
little infiltration ; other joints are involved, especially the knees, rarely 
the hip alone ; the patient is an adult ; and the usual signs above described 
for true hip disease are wanting. 

In inflammatory conditions within the pelvis, such as a perityphlitic 
abscess or a perinephritis, there is the usual sudden invasion, attended 
generally with a chill, constitutional disturbance sufficient to keep the 
patient in bed, deformity within a day or two, and increase of the de- 
formity. Palpation will enable one to recognize a deep-seated fulness 
either in the iliac fossa or in the ilio-costal space. In testing the hip as to 
function, ab- and adduction will be free, while extension will be resisted. 

In Pott's disease of the spine the limp differs from that of hip disease. 
While the child may favor the limb a little, it is not the step of fear 



OSTITIS OF THE HIP. 333 

which characterizes the limp of hip disease. All the movements are' 
normal except extension, and in Pott's disease, where it involves the last 
dorsal and first or second lumbar, there is resistance to extension by 
reason of irritation of the psoas and iliacus muscles. The absence of 
many signs that belong to hip disease will prompt one to examine the 
spinal column, to test its functions, and at the same time to explore the 
iliac fossa with the fingers. By exploring the iliac fossa I mean digital 
palpation with the thighs flexed, so that one can discover, even through 
the abdominal walls, the presence or absence of infiltration in the sheath 
of the psoas. In the Pott's disease we are now considering psoas abscess 
is frequently present, and the digital examination will enable one to 
recognize even a small abscess. 

Neuroses of the hip simulate frequently certain types of hip disease. 
In getting the history hysterical symptoms will certainly appear. There 
will be spinal tenderness, tenderness following the course of the anterior 
crural or the sciatic nerve, hypersesthesia of the skin supplied by these 
nerves, and a deformity of the hip which varies in degree from day to 
day ; that is, at times one will note scarcely any deformity, while perhaps 
the next day there will be marked flexion of the thigh. Another neur- 
osis of the hip is that dependent upon irritability of the spinal nerves, 
brought about sometimes by exposure to cold. In my own experience 
boys from ten to twelve or fourteen have presented this form of neurosis 
more frequently, and the neurosis seems to follow exposure to cold ; that 
is, I know of several instances where swimming early in the spring or 
late in the autumn has been followed by rather acute flexion of the hip, 
pain, lameness, and disability. In girls about the same age chorea some- 
times accompanies the deformity and makes the diagnosis rather difficult,, 
but, after all, a routine examination, as above suggested, will enable one 
to eliminate all of the diseases that have been mentioned in discussing 
differential diagnosis. 

The two remaining ones, poliomyelitis and malignant disease, pre- 
sent greater obstacles, and yet a poliomyelitis has such a well-marked 
history of invasion that a test of the functions of the joint will enable 
one ordinarily to make a diagnosis. If the examination be made within 
a week or two from the invasion, there is so much hypersesthesia about 
the limb and the joint itself that one must exercise great care in eliciting 
all the facts in connection with the case. 

In malignant disease the shaft of the bone or the pelvis is involved, 
rarely the head and neck, so that we must depend upon not only careful 
physical examination, but the history ; which history is replete with very 
sharp pain, burning in nature, which is not relieved by any methods 
of treatment. Fortunately, malignant disease rarely occurs in early 
childhood, so that the danger of an error in diagnosis is reduced to the 
minimum. In adult life we encounter malignant disease more fre- 
quently, and in adult life hip disease is the exception. 

Treatment. — In discussing the pathology of joint disease reference 
was made to certain principles in treatment which were to be discussed 
more fully in treating of individual joints. In the early stage the joint 
should be put at rest. It is well, just as soon as the diagnosis is made, 
to put the patient to bed with weight and pulky, and employ enough 
weight to overcome the reflex spasm and maintain a good position. 



334 



ORTHOPMDIC SURGERY. 



Relief will surely follow this method, but, as it is important to devise a 
form of treatment by which the patient can be up and out of doors, we 
fortunately have numerous appliances that can be adjusted and that can 
be easily obtained. If one is remote from a large city, it is well not to 
rely too implicitly on the various splints of the shops, but to employ 
some form of plastic dressing for the hip which can be supplemented 
by axillary crutches. What I mean is this : a neat-fitting and light 
plaster-of-Paris bandage can be applied from the free ribs down over 
the hip to the calf. In this way the points above and below the hip are 
immobilized as well. A high shoe on the foot of the sound limb, with 
a pair of axillary crutches long enough for this limb thus lengthened, 
will complete the outfit, and the patient can go about and get the benefit 
of hygiene and an out-of-door life. If one is specially skilled in the 
construction of leather appliances, a similar support can be made. It 
is necessary to bear in mind that the limb must be not only kept immo- 
bile, but the dressings must be so applied that the reflex spasm which 
occurs can do very little damage. The plaster or leather, for instance, 
which is employed should fit very snugly just above the condyles and 

about the pelvis. It should 
Fig. 338. also extend well back of 

and over the trochanter 
major. I am convinced 
that a number of cases thus 

Fig. 339. 





The plaster-of-Paris bandage (Lovett). QSy permission of Willard s hiD snlmt 

the Trustees of the Fiske Prize Funa.) ^ ^ 

taken early by the family practitioner and treated as above described can 
be cured without shortening, without deformity, and with almost perfect 



OSTITIS OF THE HIP. 



335 



function. The employment of blisters and counter-irritants is of very- 
little use, so far as my own experience goes. I am quite positive that 
counter-irritants in any form will do very little, if anything, toward 
arresting the disease, and I am sure that they will not prevent deformity. 

Unless one can adequately protect the hip while the patient is going 
about on crutches, it is better far to maintain the recumbent posture in 
bed with weight and pulley. If deformity has already arisen, then 
there is still greater need for the bed-treatment, because an inclined 
plane can be employed, and in this way traction can be made in the line 
of deformity. 

The question often asked by physicians, when to put on a splint, 
may be answered — just as soon as you can fit a splint to the patient. 
This does not mean as soon as you 

can fit the patient to the splint. Fig. 340. 

Time in bed is not time lost. The 
splint, therefore, can be used in any 
stage — can be used just as soon as 
the disease develops and before any 
deformity arises — but it should 
meet the indications : it should 
protect the joint against the trauma 
of accident and the trauma of re- 
flex muscular spasm; it should 
hold the limb taut, therefore, and 
the weight, if the patient walks, 
should be transferred either to the 
axilla or to the perineum. 

Among the splints which re- 
crutches are the 
splint, which is 

338, the Willard, 

339, the Thomas 
sphnt. Fig. 340. The Willard 
splint can hardly be employed, 
however, as a fixation splint unless 
the joint be done away with. Dr. 
Willard himself employs it in con- 
valescing cases. But with the joint 
locked it serves a very useful pur- 
pose. Its construction is very sim- 
ple, as it is made over a cast. 
The Thomas splint has a very 
extensive use throughout Great 
Britain. It is a simple posterior 
splint, but requires rather nice ad- 
justment if it is to be at all serviceable. None of the splints thus far 
mentioned are used for traction purposes. 

Orthopaedic surgeons generally favor traction. In my own practice 
I employ traction wherever it is possible to do so, but I find it necessary 
frequently to omit the traction and employ simple fixation ; for instance, 
where the limbs are excoriated from adhesive plasters or where the 



quire axillary 
plaster-of-Paris 
shown in Fig. 
seen in Fig. 
Fig. - 




Thomas splint applied. 



336 ORTHOPEDIC SURGERY. 

symptoms are very acute. In hospital practice, where the instrument- 
maker is always at hand and where the patients are under daily obser- 
vation, I find it necessary frequently to omit the ordinary traction splint 
in very acute cases, and employ until these symptoms have subsided 
some form of fixation. 

Among the traction splints may be mentioned the long traction 
splint fully illustrated in all text-books and the Phelps splint. There 
are many varieties of the splint first named, the long traction splint, 
but all embody practically the same principles that the first splint was 
intended to embody. All are modifications of the Davis splint. The 
short Sayre splint is on the same principle. 

It is difficult to estimate the value of the long traction splint ; it 
is equally difficult to decide upon its disadvantages. As a means of 
relief from pain and as a comfort to a child afflicted with hip disease its 
value can certainly not be over-estimated. To one who has observed for 
a number of years sutfering in all stages of hip disease from the painful 
spasm, from distorted limbs, from confinement to bed and crowded 
wards, a splint which enables the child to get up and out of doors, to walk 
on the perineum, and to play with other children seems an inestimable 
boon. Too much, however, is claimed for the splint. It is claimed, for 
instance, that if properly applied it will not only prevent deformity, but 
correct deformity. It is claimed that the long splint itself, in conjunc- 
tion with an inclined plane, is amply sufficient to correct the larger num- 
ber of deformities that occur at the hip. On the other hand, there are 
very good men who claim that it is not competent to correct deformity, 
and is not competent to prevent deformity. It is a useful instrument in a 
large proportion of cases. The protection it affords the joint by reason 
of the traction enables the patient to lead an out-of door life without the 
aid of axillary crutches, and where it is applied before deformity occurs 
an intelligent surgeon, with any kind of home co-operation, can certainly 
prevent deformity, as a rule. In dispensary practice this home co-opera- 
tion is so difficult to get that one sometimes despairs of conducting the 
average run of hip disease to a successful issue. Deformities do occur with 
the long splint, and it is exceedingly difficult to prevent deformity even 
after it has been corrected. In private practice I am sure that much 
better results can be obtained. The ideal hip-splint has not yet been 
invented. 

The Phelps splint is claimed by its inventor to not only prevent de- 
formity, but to secure absolute protection to the joint, and in this way it 
is thought to meet all the indications required. Yet the proof is thus 
far wanting, in my opinion, that this splint will do what is claimed for 
it. It certainly has certain advantages over the long traction splint, and 
they are these : it immobilizes the joints above and below the hip-joint, 
thus preventing any muscular action which would distort the hip ; it dis- 
tributes the weight between the perineum and axillse, or, rather, it re- 
lieves the perineum of the weight of the body and transfers it nearly all 
to the axillse. One feels, however, that if the hip can be managed with- 
out the use of axillary crutches and without immobilizing the lower part 
of the spinal column, the treatment can be made much easier for the 
patient and much less annoying to the parents. The Phelps splint is 
illustrated in Fig. 341. 



OSTITIS OF THE HIP. 



337 



Fig. 341. 



All important question which one is called upon to decide is, How long 
must the splint be worn ? If a case can 
secure the advantages of the long traction 
splint before the stage of deformity — that 
is, the first stage of the disease— it requires 
from one to two years' continuous use of 
the splint to effect a cure. I have never 
felt that one could get the best results by 
using a splint by day and weight and pul- 
ley at night. The child should sleep in 
the apparatus. Care should be taken to 
see that good traction is made, especially 
at night, and maintained throughout the 
day. If the use of the splint is begun 
after deformity has arisen, in the sec- 
ond stage, the time requisite for the best 
result is from three to four years. It is 
in this stage where abscess is likely to 
occur, where already important changes 
have taken place, not only in the head of 
the bone, but about the joint itself. The 
process of resolution is exceedingly slow. 
A splint is applied in the third stage very 
often after the correction of deformity, 
by some surgeons before deformity is cor- 
rected, and it is in this stage that it is dif- 
ficult to name any time for the wearing of 
the splint. If one is satisfied that the dis- 
ease is fully arrested, the splint need be 
worn for from six to eight months after 
the correction of deformity. Convales- 
cing splints are employed toward the close 
of treatment. There is no question more 
difficult to decide than when a good protection splint may be dispensed 
with and a convalescing one substituted therefor. 

The ordinary tests of cure are unsatisfactory at best. Many ortho- 
pedic surgeons of very large experience claim that there is disease pres- 
ent so long as reflex spasm exists, and there are many surgeons who are 
never able to decide when reflex spasm ceases. About the best test, in 
my own experience, is that which was formulated by the late Mr. Hugh 
Owen Thomas — namely, the test of function. His plan was to remove 
the apparatus when he felt that the joint had been protected a sufficient 
length of time and when there were no inflammatory products to be recog- 
nized about the hip. At the end of a week he made another exami- 
nation, and if he found that the range of motion had increased, he was 
positive that the disease was fully arrested. If, on the other hand, the 
range of motion had decreased, the splint was reapplied, and he felt sure 
that longer protection was required. In my own practice I employ at the 
period when Mr. Thomas would remove the apparatus a convalescing 
splint, which is a splint that does not employ traction, that gives motion 
at the hip, knee, and ankle, and is really the Dow's splint of Taylor. 

Vol. II.— 22 




Phelps's eombmation traction hip 
splints 



338 ORTHOPEDIC SURGERY. 

This apparatus has served me a very good purpose, and, while it is true 
that circumstances sometimes compel me to return to the protection 
splints, in the majority of instances this necessity does not arise. 

In closing these remarks on the use of apparatus I wish to guard my 
readers against the improper use of the adhesive plasters, and to dwell 
upon the necessity for protection of the knee-joint during the entire 
course of treatment. In employing adhesive strips for traction the plas- 
ters should be long enough to extend from the upper third of the thigh 
to a point about two inches above the malleoli. Not only should the 
plasters be this long, but the surgeon should see that they adhere closely 
to the thigh, so that too much traction may not be made upon the knee- 
joint itself. As a result of the improper application of plasters and of 
the failure to protect the knee I have seen great laxity at the knee-joint, 
and a very marked recurvatum develop toward the close of a long course 
of splint-treatment. The Judson knee-piece, which is well known now 
among orthopaedic surgeons, is a U-shaped steel support which is attached 
to the stem of the splint and affords ample protection to the knee. After 
a case has been cured it is necessary to occasionally observe the patient, 
so as to protect him against these later deformities at the knee. 

For the correction of deformity various methods are employed. The 
most common is traction, either by means of the splint or by means of 
weight and pulley on an inclined plane. For this purpose it is better to 
have the patient in bed, or at least in a recumbent posture. In place of 
the bed a wheeled chair may be employed if the proper framework is 
attached to the chair. That which seems to me the best kind of appa- 
ratus is the Cabbot frame. After using various appliances of this kind I 
find that I get best results with this modified frame. The weight over 
the foot of the bed is difficult to keep in good position ; it does not con- 
tribute to the cosmetic effects of the sick-room, and especially in a hos- 
pital ward it has the appearance of cruelty ; hence I have for a long time 
now employed the windlass at the end of the inclined plane. I can thus 
get any amount of traction I choose. If I want elastic traction, the 
elastic pieces can be attached to the stirrup and thence to the adhesive 
strips on the limb. Counter-extension is afforded by the pelvic band. 
It must be borne in mind that traction must always be made in the line 
of deformity. After a week or two the plane can be lowered, and so on 
until the deformity is fully corrected. 

If one cares to use the hip-splint, the whole limb encased in the splint 
can be put upon this inclined plane, and by means of the rack and pinion 
attached to the splint sufficient traction can be made. 

Where this means fails, manual force, supplemented by subcutaneous 
myotomies, can be employed, the deformity partially corrected, and a 
plaster-of-Paris bandage employed, followed by rest in bed for one or two 
weeks. Then the process can be repeated, and so on until the deformity is 
overcome. It must not be understood that by manual correction is meant 
brisement forcL This term as employed in surgery carries with it the idea 
of forcible movements in flexion and extension, and has been employed 
in connection with the treatment of ankylosis. Manual force, therefore, 
means careful manual force — a steady pull in the line of deformity, 
accompanied by a gradual extension. 

When these means fail an osteotomy below the trochanter minor is a 



OSTITIS OF THE HIP. 



339 



most excellent method of treatment. This operation is easily performed, 
and with a novice should be done by the open method. If one is skilled 
in subcutaneous surgery, a small osteotome, quite sharp at its edges and 
rather narrow, can be easily inserted through the skin down to the peri- 
osteum, and the bone severed throughout nearly the whole of its thick- 
ness. Then a little manual force employed will serve to complete the 
solution of continuity. A simple fracture will thus be produced, and a 
plaster-of-Paris bandage from the axillte down over the hip to the foot 
makes the best dressing for a fracture of this kind that can possibly be 
devised. I speak advisedly on this subject, because I have employed 
the plaster with such uniform success. If one, however, is not familiar 
with the use of plaster, as has been remarked before, then a long side 
splint from the axilla to the foot, with the limb and body securely bound 
to the splint, and this supplemented by traction with weight and pulley, 

Fig. 342. 




will make a very safe dressing. Fig. 342 is a very good illustration of 
a hmb that has been corrected and encased in plaster of Paris. 



340 OBTHOP^DIC SURGERY. 

My plan is to put the child to bed immediately after the plaster is set, 
and at the end of two weeks use a wheeled chair ; at the end of six weeks 
remove the plaster, when union is, as a rule, found very firm. While the 
patient is waiting for an apparatus to maintain the good position, for 
some months afterward I employ weight and pulley in bed. The appa- 
ratus I employ is a spinal brace with a stem running down over the hi}? 
to the lower third of the thigh. A lever is thus secured for the limb ; 
the fulcrum is just back of the trochanter major, and the whole apparatus 
can be secured more accurately by means of a roller bandage. If one 
finds it difficult to apply the bandage properly, a canvas lacing can be 
made, which will answer an admirable purpose. Axillary crutches are 
now to be used for a few weeks, these finally abandoned, and the differ- 
ence between the limbs made up by a high shoe. I have found it neces- 
sary to employ this apparatus for a period of from six to twelve months 
to guard against relapse. In volume vii. of the Transactions of the 
American Orthopaedic Association I have recently published a paper on 
this subject — a paper which is well illustrated. 

Operative procedures on the hip include evacuation of abscesses, ex- 
cision of abscesses, the curetting of sinuses, the gouging out of foci of 
disease in the bone, partial arthrotomy, excision, and amputation. 

In the treatment of abscess one must be guided by the general con- 
dition of the patient and by the location and severity of the abscess. By 
the condition of the patient is meant either an excellent condition of 
health or a very much impaired condition. If the former, there is really 
very little occasion for operative interference, for the reason that the 
abscess is not acute, and that many abscesses in patients in good condi- 
tion of health undergo absorption and finally disappear. There are some 
surgeons who believe it wise to evacuate every abscess, but these siu-geons 
are in the minority and belong to what is known as the bolder class. 
The more conservative surgeon, no matter how successful he mav be or 
how good his judgment, does not look upon a cold abscess as at all detri- 
mental to the health of the patient or as interfering with the ultimate 
recovery of the bone whence the abscess comes. 

If the patient is in poor health and the abscess seems, after a little 
observation, to be an important factor in perpetuating this ill condition 
of health, then it is the duty of the surgeon to dispose of it as early as 
possible. 

The location of the abscess has much to do with whether it shall be 
left alone or treated surgically. For instance, if it is in the w^ay of the 
proper adjustment of a protection splint, then interference is called for. 
If it encroaches upon the deep femoral vessels, it is well to interfere. 
If, again, the abscess is specially large and is increasing rapidly, so that 
a large area of tissue in the gluteal region or in the upper part of the 
thigh is involved in the dissection of the abscess, then operative inter- 
ference is called for. It should be borne in mind, however, that a great 
many abscesses open spontaneously and that excellent results follow, 
while an equally large number, after a spontaneous opening, go on to 
further suppuration, progressive exhaustion of the patient, finally the 
development of amyloid degeneration of liver and kidneys ; which degen- 
eration of itself is, as a rule, fatal. 

The operative procedures are — simple aspiration ; aspiration followed 



OSTITIS OF THE HIP. 341 

by the injection of some aseptic agents, such as carbolic acid, creasote, 
iodoform, and iodine ; simple incision, the opening being large enough 
merely to permit of escape of the contents of the sac ; free incision ; 
free incision followed by dissection or complete destruction of the sac 
itself. This latter may be followed by exploration of the bone-focus 
and removal of all the diseased material in the bone. 

After a very extensive experience in the management of abscesses by 
means of the aspirator and the aspirator combined with injections of 
various kinds, my preference is largely in favor of simple aspiration. I 
make this statement, notwithstanding the increasing testimony in favor 
of injections of various agents, because at the hospital I have analyzed 
from time to time a series of cases treated after the various methods, 
and the best results, I am sure, are attained by simple aspiration. This 
plan of treatment has become so popular with me that I make it a rule 
to subject all abscesses to aspiration. 

When the sac is filled with extensive sloughs of cellular tissue, which 
sloughs plug up the needle at every insertion, I resort to incision, pro- 
vided the location of the abscess is favorable for incision. I am not 
quite sure but that a small incision in a large number of cases, with 
pretty free irrigation of the sac and an antiseptic dressing, is better than 
the free incision. It is certainly better than the free incision unless the 
latter is attended with a thorough dissection of the walls of the sac. 
Where one is prepared to carry out all the details of thorough dissection 
of the sac I would advocate this plan for the class of cases which may 
be described as follows : an abscess that has existed for a long time, say 
several months, that has made little or no increase in size, and that con- 
tains pus either too thick for an ordinary needle or contains a cheesy 
mass ; a very large abscess which has burrowed extensively and en- 
croaches upon important structures, such as the blood-vessels, or that 
interferes with the proper application of the splint ; an abscess which is 
attended with a daily rise of temperature and that is interfering with 
the nutrition of the child. Such abscesses as I have just described are 
suitable, in my judgment, for the treatment proposed. It is very easy 
to dissect an abscess, to sew up the wound, and to get primary union, 
but if one fails to follow up the track and remove the bone, the chances 
are that at least 50 per cent, will recur and that subsequent openings 
will have to be made. While I have no figures bearing on this subject, 
my hospital experience enables me to make this statement thus approx- 
imately. Did space permit, I am sure I could report a number of cases 
which go to bear me out in this opinion. 

The treatment of sinuses is a most perplexing one, and I am free to 
say that, at present, I have no specific to commend. The various agents 
for closing a sinus are all commendable, yet time and again I have 
regretted closing a sinus, for the reason that the pus must find exit, and 
there is no better way for the pus to escape than through one or two of 
these old sinuses. After the discharge become insignificant, then the 
curetting of the sinus may be adopted, this curetting to be followed by 
thorough flushing, and the injection of peroxide of hydrogen or creasote 
or iodoform and oil. 

The removal of foci of disease in the bone is certainly to be com- 
mended in many cases. If one can be satisfied that the focus can be 



342 ORTHOPJEDIG SUBGERY. 

reached without too free gouging of the joint itself, then one's duty- 
is clear. The trouble, however, is that there are many foci, and the 
removal of one does not relieve the others. On the contrary, it is well 
established that an incomplete operation serves sometimes to disseminate 
the bacilli and to rather aggravate the original disease. The plan of 
drilling the neck through the trochanter major promised brilliant results 
a few years ago, but experience has shown that the disease is not always 
confined to the neck, or even the epiphysis, and for this reason the 
operation has not been so extensively resorted to within the last few 
years. 

The operation of arthrotomy or partial artheotomy is more especially 
applicable to the knee, and has never gained many adherents where the 
hip is concerned. The simple removal of the synovial sac and the soft 
structures, even the cartilage lining the acetabulum and covering the 
head, does not reach the seat of disease, and wlien one goes thus far it is 
regarded as the part of prudence to remove the head of the bone. 

Excision of the hip is an operation that is called for in a certain 
proportion of cases. A very thorough study of the subject has not 
inclined me to early excision, but the cases for this are those which 
have failed to improve under the protection splint, under good hygienic 
surroundings, and which seem to go from bad to worse. Statistics 
bearing upon the subject are of little value, for the reason that most 
men make a selection of their cases and final results are difficult to obtain. 
The brilliant work of two London surgeons a few years ago led us to 
believe that a thorough aseptic excision, with complete removal of all 
diseased structures, could be done, and that primary union would result. 
Subsequent teachings and subsequent observation of the cases operated 
upon in this way lead us now to believe that the ideal method has not 
been attained. If one excises early, he is bound to get a large number 
of good results. If he excises late and as a dernier ressort, he is bound 
to get a large number of failures ; but, after all, the failures can scarcely 
be regarded as failures, because these cases were necessarily doomed and 
the excision was a life-saving method. It is a fact well established that 
hospital and dispensary cases demand excision much more frequently 
than those in private practice. The former class usually occur in chil- 
dren of shiftless parents — parents who are poorly trained in the sense of 
co-operation, and who have never learned to set any correct value upon 
the splint treatment ; while in private practice the surgeon, as a rule, has 
intelligent co-operation. He has more time to instruct the families, 
and in addition to this the parents themselves enjoy better hygienic 
surroundings. 

The question of what incision is the best for an excision is largely a 
personal one, and must always depend upon the individual judgment of 
the surgeon. Where the bulk of the supjjuration is in the gluteal region 
or posterior aspect of the thigh either the incision of Sayre or the straight 
incision posteriorly is recommended. Where the bulk of the suppura- 
tion is in front, however, the anterior incision is by all means preferable. 
I have long since abandoned the saw, and the chisel and gouge are used 
exclusively in excision of the hip. With curved scissors and forceps as 
supplemental instruments all the diseased tissues can be easily removed. 
For the reason that a focus is usually found in the trochanter, it is best 



MINOR DISEASES OF THE HIP. 343 

to remove this portion of the bone as Avell as the neck. Furthermore, 
better drainage is afforded, and the ultimate function of the joint is not 
impaired by removal of the trochanter. Where one is satisfied that all 
the diseased bone has not been removed, the larger part of the wound 
should be left open and further drainage established. The limb may be put 
up in a wire cuirass or on an ordinary Thomas hip-splint with traction by 
weight and pulley. On account of the ease with which I can employ 
plaster of Paris, I dress most of my cases with a firm plaster-of-Paris 
bandage, applied from the free ribs to tlie ball of the foot, making a snug 
fit just above the condyles and above the malleoli. A fenestrum is cut 
in the plaster, and through this the wound can be dressed as often as is 
necessary. 

It does not follow because a hip is excised that the treatment has been 
exhausted. If, for instance, the treatment should seem to fail of good 
result and the suppuration should persist, it is the surgeon's duty to 
follow the operation up with further procedures, draining pockets where 
found, freshening up old sinuses, removing any bits of bone that may be 
retained by the healing process. In other words, the case should be con- 
ducted to a successful issue if this is possible. The results are very 
gratifying in properly-selected> cases. Even in cases that are operated 
on as a dernier ressort brilliant results follow. 

It is the practice of many surgeons to omit apparatus as soon as the 
sinuses are healed or even long before this period, yet I am forced to 
believe it unwise, for the reason that deformity is apt to recur many 
months after the closure of all sinuses. Flail joints are sometimes 
reported after the operation, but I am convinced that they are rare. 
Such a result can only follow a very extensive removal of the shaft of 
the bone. Removal of the shaft is sometimes required where there is an 
extensive osteomyelitis. The propriety of thorough curetting of the 
medullary canal is questionable. A bone that is so thoroughly diseased 
as to require this procedure would be better treated, in my judgment, by 
a complete removal of the member, although from the reports of Dr. 
Charles T. Poore of this city good results have followed curetting. In 
my own experience I have had no such results. Destruction of the 
acetabulum, iliac abscesses, extensive disease of the ilium, are not con- 
traindications to the operation, because all disease can be removed and 
good drainage can be established. 

Amputation of a hip is called for when the entire shaft of the femur 
is diseased, where a thorough excision has not only failed, but is fol- 
lowed by amyloid changes in the liver and kidney, and where all dis- 
eased processes cannot be removed in any other way. The proportion, 
of course, of cases for amputation is small, but yet indications do arise 
for this extreme measure, and the life of a child should not be abandoned 
when there is a possibility of saving it by amputation. 

Minor Diseases of the Hip, inclttding Congenital Dislocation. 

Under this heading may be included periarthritis, periostitis of the 
shaft near the hip, synovitis, bursitis, neurosis. 

A periarthritis is usually phlegmonous in character, proceeds rapidly 
to deformity of the joint, produces constitutional disturbance which is 



344 ORTHOPEDIC SURGERY. 

entirely different from that produced by chronic ostitis of the hip, and 
runs a comparatively short course. The diagnosis can be made with 
comparative ease, generally by exclusion, and the treatment should be 
rest in bed and hot fomentations; these failing, there should be free 
incision. The abscess is always an acute one and demands the ordinary 
surgical procedures. 

Periostitis is a little more difficult of recognition, is essentially chronic, 
and a diagnosis may be reached by exclusion. Palpation is an important 
method of examining. The existence of localized tenderness and swell- 
ing about the bone itself, with the history of an injury, goes to make up 
the essential features in the diagnosis The treatment is protection to the 
joint — for the reason that the head and neck may become involved by 
contiguity — blisters to the parts or some other form of counter-irritation. 
Really the best method, however, is a free incision down to the bone, 
with an opportunity of the parts to heal from the bottom. 

Synovitis of the hip is very rare, but is occasionally met with. It 
occurs in children from ten to fifteen years of age. It is acute, invasion 
is sudden, and the entire course does not extend over a period of ten 
weeks. The joint-tenderness is very marked. The patient after the first 
twenty-four hours is unable to walk. The flexion of the limb comes on 
early, within the first few days ; the entire limb is held with a great 
amount of care. The diagnosis is reached by exclusion. There is a cer- 
tain degree of tension in the gluteal region. The distention of the joint 
can be made out by close manual examination. There is absence of the 
ordinary signs that accompany a chronic disease. The treatment is rest 
in bed. The limb should be maintained in that position which is the 
most comfortable. Fomentations may be applied, or fly blisters. Aspi- 
ration or puncture of the joint is not called for, for the reason that there 
is nothing to gain specially by rapid removal of the fluid. It is absorbed 
within two or three weeks, and the recovery is perfect. 

Bursitis is met with occasionally in the bursa in the gluteal region, 
about as frequently in the bursa on the outer side of the hip under the 
vastus externus. Such cases occur usually either after twelve years of 
age or in early adult life. They date from an old strain or injury of 
some kind. There is very little atrophy of the limb. There are long 
periods of remission without any signs worth considering, no very acute 
symptoms even during exacerbations — simply a little lameness, disability, 
dread on the part of the parent and family that serious mischief will 
follow. A careful examination of the parts, with a clear insight into the 
history, will enable one usually to recognize these inflamed bursES, and 
treatment will depend a good deal upon the severity of the case. The 
mechanical appliance which has proved serviceable in my own hands is 
a simple straight splint attached to a pelvic band, with or without motion 
at the joint — without motion at first, later with motion, giving simply a 
hinge-jointed movement. This splint must extend down to the shoe, 
Avith a free joint at the knee and a free joint at the ankle. It can be 
secured to the limb by thigh- and calf-bands and by a perineal strap to 
the pelvic band. This splint prevents rotation of the limb, and in this 
way affords rest to the parts under the vastus externus. It is applicable, 
therefore, for inflammation of this bursa. In a number of instances I 
have aspirated the bursa and made compression, only to get temporary 



MINOR DISEASES OF THE HIP. 345 

relief. In one instance I dissected out the bursa, with subsequent use 
of an ajDparatus, and finally got a good result. 

Neuroses of the hip are so intimately associated with the hysterical 
element that hard-and-fast lines of treatment cannot be laid down. 
They are interesting simply from a diagnostic point of view. The diag- 
noses are usually easy, because of the age at which the deformity occurs 
and of the general neurotic condition of the patient. The deformity is 
usually that of flexion and adduction. The lameness is very marked at 
times. There is a good deal of hypersesthesia along the course of the 
anterior crural or sciatic nerves. There is spinal tenderness, as a rule ; 
absence of joint-tenderness, though sometimes this may be present ; 
absence of atrophy of the limb. In hysterical subjects, therefore, the 
treatment should be adapted to the hysterical condition, yet it is true 
that counter-irritation of the spine and in the course of the distribution 
of nerves does bring about sometimes brilliant results. In the neuroses 
which depend upon exposure to cold in children past the tenth or twelfth 
year there is nothing quite so good as a fly blister to the lumbar spine. 
This should be applied at night, should be two inches in width by six 
inches in length, should be left on all night. The blistered surfaces 
should be dressed for three days every six hours with hot flaxseed poul- 
tices. I am thus dogmatic on this question, because I have seen many 
brilliant results follow this line of treatment. In fact, it is the excep- 
tion that a good result has not followed. 

Congenital Dislocation of the Hip. 

This is a deformity for which very little has been done in the way of 
mechanical appliances. It is true there are a few oases on record wherein 
long persistence in the use of traction and reposition of the limb has 
resulted in what seems to be a prominent reduction of the deformity. 
The very nature of it would seem to be an insuperable obstacle to a cure 
by mechanical devices. We have not only an ill-shapen head of the 
femur, but usually the neck is distorted as well. A portion of the 
acetabulum is wanting. Nature has failed to make a proper receptacle 
for the head. During the early years of life use of the limb favors 
shortening of important muscles about the hip. The capsular ligament 
is altered in shape and in structure, so that, however well we may suc- 
ceed in pulling the limb down into position, there is nothing that will 
hold it in place so well as a good rim to the acetabulum. 

It is unnecessary to go into further detail about the etiology and 
pathology of congenital dislocations of the hip, because all the text- 
books on surgery and all the treatises have dealt so fully with the sub- 
ject. I have for a long time entertained the opinion that a long traction 
splint, with a rigid pelvic band, under the daily observation of a well- 
trained nurse for a period of from two to three or four years, will result 
in a small proportion oi cures. I have effected one such myself, but the 
time that has elapsed since the removal of all apparatus is not yet suf- 
ficiently long to enable me to predict the end-result. 

We come, therefore, to the operation which has found such able ex- 
ponents in Dr. Albert Hoffa of Wurzburg and Dr. Lorenz of Vienna. 
Their operations differ really very little in essential features. Hoffa's 



346 ORTHOPJEDIC SURGERY. 

operation is a posterior incision, straight one ; Lorenz's is an anterior. 
Both aim to get to the joint and expose the acetabulum with a minimum 
amount of diificulty. The structures to be divided are about the same. 
Bradford of Boston has made a suggestion — and, indeed, has acted upon 
this suggestion — which is certainly a very important supplement to the 
operation of Lorenz. He has found that division of the Y-ligament 
enables him to bring the head of the bone down into normal position 
without such extensive division of the muscles attached to the shaft. 
The cardinal point is to make a sufficiently deep acetabulum, and one 
in M'hich the head of the bone will lie easily without traction. Trac- 
tion, of course, is to be employed in the subsequent treatment. The 
wounds should heal promptly, and the cicatrix that results will assist in 
maintaining the head of the bone in position. From a limited experi- 
ence in the operation I am convinced that it requires a great deal of dex- 
terity, and that a large number of operations must be performed before 
one can feel justified in making a good prognosis. It is a tedious ope- 
ration, an enormous amount of violence is done to the tissues, and the 
shock is necessarily great. The results, so far as I have been able, to 
observe them, are not brilliant and are rather discouraging. I make 
this statement from my own experience. Both Lorenz and Hoffa speak 
very enthusiastically of the operation, and record what seem to be 
excellent results. The procedure, therefore, is at present sub judiee, 
and it is unwise to make any extravagant statements until more final 
results can be obtained. Among some cases of my own, recently pub- 
lished, I procured photographs of a case before and after operation. 
The deformity in this case was overcome ; the limb was held in good 
position up to the time of the patient's discharge, which was six or eight 
months after all wounds had healed. 

As a rule, young children, under the age of three years, are better 
cases upon which to operate. After the ninth or tenth year has been 
reached it is difficult to obtain a good result. 

The deformity itself is not a hideous one where both hips are involved. 
The gait is sometimes rather graceful. I am convinced that it can be 
improved upon by a certain amount of attention and education. Where 
one side is involved a high shoe can make up the difference and a very 
easy gait can be attained. It is true, we have the limp, yet the little 
patient can walk long distances and can indulge in all the plays that 
other children enjoy. It is the exception for any painful conditions to 
follow in after years. Such an exception I have recently had under 
observation, but relief was afforded by a snug abdominal bandage, which 
made very good pressure over the hip. Spinal braces accompanied by 
perineal straps really do very little, but these are recommended by some 
authorities, and in obstinate cases, where the operation is not to be con- 
sidered, are advisable. 

Tdbeeculab Ostitis of the Knee. 

The most frequent and most important disease which affects the knee- 
joint is the one which heads this section. The synonyms are White 

swelling (tumor albus), Strumous arthritis, Scrofulous knee. Fungous 
arthritis, Articular ostitis, and Tubercular ostitis. Eeally, the best term 



TUBERCULAR OSTITIS OF THE KNEE. 347 

for popular use is white swelling. Following the plan already set forth, 
the term tubercular ostitis fixes the pathology upon one's mind and 
carries with it a pretty intimate knowledge of the nature of the disease. 
The etiology and pathology have already been discussed. 

Clinical History. — The disease belongs essentially to childhood, and 
the ages between which it is most common are two and ten. The first 
symptoms noted are pain on handling the limb and on using it in walk- 
ing, and the signs are extra heat over the knee, with slight reflex spasm 
when flexion approaches the limit. It is usually the frail member of the 
family that is afifected. The first impression is that an injury has been 
sustained, and it is easy to get a history of a trauma as the cause ; yet, as 
in the other joints discussed, trauma is found on cross-examination to 
play a very unimportant part in the etiology. 

The child favors the limb in walking a little — complains of a little 
stifihess. A sprain or twinge of rheumatism or the beginning of a bad 
habit is diagnosticated by the family. The exacerbation, like that where 
other joints are involved, may be very slight and may extend over a few 
days or a week. Then a remission occurs, which is regarded by the 
parents as complete. Surgical or medical services are not usually sought 
in these milder cases until the second or third exacerbation appears. The 
limb during this first remission appears to be normal, but if one were 
called upon to make an examination it would be found that the function 
was not quite as good on the affected side as on the sound side. The 
contour of the joint, it is true, would show very little change, but to a 
critical eye the depression on either side of the tendon of the quadriceps 
would be less pronounced than in the normal condition. The ligamentum 
patella would appear a little broadened. In the midst of the exacerba- 
tion there often is a moderate distention of the synovial sac, and the case 
looks at this period very much like one of acute synovitis, but the history 
of the former exacerbation and of a remission would enable one to rule 
out acute primary synovitis. Yet it is true that this diagnosis is more 
frequently made than any other. If the patient be subjected to treat- 
ment during this second or third exacerbation, while the signs are not 
very pronounced, rest in bed will relieve to a certain extent, and a re- 
mission less pronounced than the former ones may follow. The epiphyses 
gradually become enlarged, the function of the joint is imjjaired, and the 
first stage, which is the stage preceding deformity, merges gradually into 
the second, that of deformity. 

Deformity is characterized by slight flexion and marked change in con- 
tour of the limb ; that is, increase in size with obliteration of the normal 
depressions. The lameness now persists, and is so uniform in character 
that a knee-limp is easily recognized, the limp characterized by a short 
step, a disposition to walk on the toe and ball of the foot, to lean to that 
side and favor the limb. 

Atrophy is an early sign, and persists throughout the entire course of 
the disease. Exacerbations are induced by trauma, and deformity, such 
as subluxation or luxation, is the natural result of the use of the limb, 
aggravated by the reflex spasm of the flexors. There are various grades, 
dependent more or less upon the number of foci. A focus may exist in 
the head of the tibia, and very little deformity will result. It may be 
confined to the lower epiphysis of the femur, in which event deformity 



348 ORTHOPEDIC SURGERY. 

is more apt to follow. It is possible for the disease to extend over a 
period of years and still produce very little deformity ; yet the rule is 
to have a peculiarly shaped limb, such as has been described, and which 
is so well shown in most of the text-books and brochures on this 
subject. The third stage is marked by luxation or subluxation, by a 
bulbous appearance of the lower end of the femur, enlarged veins, and 
abscess which may have opened spontaneously or been incised, leaving 
sinuses. Where resolution takes place only the deformity will remain, 
but where the disease progresses from bad to worse there will be exten- 
sive suppuration about the knee, in the thigh, and in the calf. The 
suppuration will finally have its effect upon the constitution — emaciation, 
amyloid changes in liver and kidney, etc. etc. 

Pain is not a persistent symptom, but is present in all exacerbations ; 
it is very severe when an abscess has just begun to form, especially if 
the abscess be deep-seated and the pus presses upon important structures 
in its attempt to get to the surface. 

In an analysis of 300 cases, made in 1893, 1 found that 140 had 
abscesses, 160 never had abscesses at any time; 40 died. The cause of 
death was tubercular meningitis in 6 ; exhaustion after prolonged sup- 
puration in 14 ; phthisis in 3 ; dysentery in 2 ; amyloid degeneration in 
2 only; and 12 of this number from intercurrent affections which had 
no connection whatever with the disease ; 1 died from shock after an 
excision. With 22 deaths as a direct result of the disease we have a 
mortality of 7| per cent. 

Diagnosis. — From the clinical history the diagnosis should be 
comparatively easy. It is not difficult if one makes a careful and 
comparative examination of the limbs. The same remarks apply 
with equal force to diagnosis here as in affections of the hip and spine. 
In making a differential diagnosis one must be able to rule out 
acute primary synovitis, a severe strain or contusion, a periarthritis, a 
rheumatic arthritis, a bursitis, derangement of the cartilages, and 
neurosis. 

An acute synovitis is very distinctive. The synovial sac is distended 
with fluid, and no other parts of the knee, such as the sides and poste- 
rior aspects, are involved. There is a certain amount of flexion de- 
pendent upon the amount of fluid in the knee. There is a history of a 
trauma, usually in close relationship with the symptoms. It is true a 
synovitis may be but an expression of an exacerbation, and it may 
appear during the first exacerbation. In this case a differential diag- 
nosis cannot be made at a single observation. 

Severe strain or contusion is attended with signs of injury to the 
soft parts, such as laceration of the skin, ecchymosis, and superficial 
swelling. It of course has the history of injuryiramediately preceding 
or preceding by one or two days only. If the deeper structures are 
involved, the diagnosis must be made by exclusion ; that is, one must 
exclude a dislocation of the semilunar cartilage, a detachment of some 
of the fibres of this cartilage, a chipping off of the patella or the tibia 
about where the ligamentum patella is attached. 
^ A periarthritis is usually a cellulitis, involves the soft structures, is 
often phlegmonous in character, and need not depend upon trauma as a 
cause. It is acute as a rule. The remarks just made apply t« the 



TUBERCULAR OSTITIS OF THE KNEE. 349 

periarthritis as it occurs in children. In adults we have a rheumatoid 
or rheumatic periarthritis, which involves the capsular ligament and the 
structures intimately surrounding the joint. If one can feel a distinct 
grating like that of rice-bodies or sand as the knee is flexed and ex- 
tended, a diagnosis of rheumatic periarthritis can be easily made. If 
the signs just mentioned are absent, then the case will require a little 
closer observation. Examination of the urine will sometimes assist in 
completing the evidence in the case. 

Kheumatic arthritis is usually associated with a periarthritis, but 
may be entirely independent of any periarticular lesion. The sensation 
imparted to one's hand as the limb is moved is significant, and if to this 
be added a similar sensation in other joints, especially the other knee, 
ostitis can be easily eliminated. 

The bursas about the knee are not infrequently involved in a sub- 
acute form of inflammation, depending upon trauma and occurring 
usually in ball-players or athletes generally. The bursa in the popliteal 
space is sometimes affected by a sharp flexion of the limb, and a severe 
concussion or bruising added to this. The diagnosis is made when such 
is the case by a careful comparative examination of the limbs, by close 
attention to the history given, and by the absence of signs pointing to a 
lesion in the joint or in the parts in the anterior surface of the limb. 
A rare form of bursitis occurs in the bursa between the ligamentum 
patella and the top of the tibia. This can be made out by a comparative 
examination and by a process of exclusion. The bursa between the 
quadriceps extensor tendon and the thigh has a communication with 
the joint itself, and it is difficult to dissociate the bursitis here from an 
arthritis. If this bursa can be made out very much enlarged and the 
joint itself proves to be very slightly affected, then one can easily speak 
of a bursitis in this locality. Where other bursas are involved it is more 
than likely that they must be associated with a general arthritis or 
periarthritis. 

By derangement of cartilages is meant either a luxation or a sub- 
luxation of the semilunar cartilage, varying in degree and including 
lacerations of the posterior or anterior attachments. A complete dis- 
location of the semilunar cartilage is so rare that an extended description 
is unnecessary. The subluxated semilunar cartilages are most frequently 
met with, and are produced by a sharp flexion of the knee with a rota- 
tion inward or outward. If outward, the internal semilunar, if inward, 
the external semilunar, cartilage is slightly displaced. If one can ex- 
amine shortly after the trauma which is nearly always the cause, the 
cartilage itself can be recognized lying along the upper border of the 
tibia, and can be brought out in relief by sharply flexing the knee while 
the examination is made. The existence of tenderness along this line, 
with the absence of tenderness in other parts of the joint either within 
or without, enables one to make a diagnosis. If the examination is not 
made shortly after the original injury, but at a later period, one must 
look for a history of exacerbations, and the patient will usually describe 
certain slipping sensations when the limb is flexed, associated with inter- 
nal or external rotation. It must be understood also that these exacer- 
bations are attended with a limited area of arthritis, sometimes peri- 
arthritis. If this is understood, then the significance of the arthritis 



350 OBTHOP^DIC SURGERY. 

can be properly estimated and the essential points of the diagnosis be 
established. 

Loose bodies may be classed under internal derangement of the knee. 
These are known as loose cartilages sometimes, and occasion often a 
rather acute attack of arthritis. They slip about just as a semilunar 
cartilage does, with the exception that their location is different. The 
sensation of the patient can be relied on a good deal in making a diag- 
nosis, for the bodies themselves can be distinctly felt at times. 

The neuroses of the knee are characterized simply by an absence of 
any physical signs other than a flexion. This flexion is clearly due to 
spasm of the hamstring group, and is associated with irritable spine. 
The points brought out in differential diagnosis of the hip are applicable 
to the knee quite as well. 

" Charcot's knee," as it is called, is associated with tabes dorsalis, 
and may in the earlier stages present signs that will be extremely con- 
fusing. The extreme laxity of the joint-structures with lateral de- 
formity, sometimes marked subluxation and even luxation, are charac- 
teristic signs in the tabetic joint. Occasionally an extreme degree of 
hydrarthi'osis is present. 

In enumerating the points in differential diagnosis no reference was 
made to sarcoma. It is just as well, however, to include this in the 
differential diagnosis. In sarcoma the bony enlargement extends some 
distance above or below the joint, and is really a sarcoma of the femur 
or of the tibia. The joint itself participates only secondarily, yet so 
long as it is involved the signs are those of osteo-arthritis. One pre- 
dominant feature is continuous boring pain. To this is added a slow 
growth, with often a pulsation imparted to the hand. This pulsation is 
almost pathognomonic of sarcoma. While it is not present in all cases, 
when found it is of great value. 

Treatment. — To successfully cope with tubercular ostitis of the knee 
one must be prepared to carry out the most efficient protective meas- 
ures over a long period of time, as well as to interfere with operative 
procedures A\'hen occasion demands. The treatment, therefore, is me- 
chanical and operative. The term "expectant" is very often used, 
meaning the treatment without resort to operation, but in the broader 
sense of the term " expectant" operations are frequently demanded. For 
example : The term itself means to treat symptoms and signs as they 
arise, to combat abscess, deformity, and destructive bone-changes. The 
aim is to conduct the joint through the different stages of disease to the 
best possible function, such as a good range of motion and freedom from 
shortening and deformity. The surgeon, therefore, who treats a case 
expectantly must not only prevent the reflex spasm which is an import- 
ant element in the causation of pain, but resort to the correction of the 
deformity by manual force, mechanical appliances, or the knife, saw, 
and chisel. The better division, therefore, to make, in my judgment, 
is mechanical and operative. At the same time, it must be understood 
that one supplements the other — that even after operative interference 
mechanical appliances are to be employed, that the best possible results 
of the operation may be attained. 

Splints of various kinds are used to immobilize the joint. Immo- 
bilization of itself is a very important element in the management of 



TUBERCULAR OSTITIS OF THE KNEE. 



351 



ostitis, but rest to the articulation is quite as important. We speak, 
therefore, of fixation and rest as necessary to adequate protection. 
To fix a joint so that no motion can take place, and yet allow the 
patient to bear the weight of the body upon the foot, is, in my 
opinion, a very reprehensible treatment in the acute stages of an 
exacerbation, and — as exacerbations are frequent and come on with 
very slight provocation — it is unsafe to rely upon periods of quiescence 
during which the joint may not need rest. The trauma that comes from 
use is the chief cause of exacerbations, especially when fixation is em- 
ployed. The trauma that comes from reflex spasm, of course, is quite 
as baneful as the trauma from use. To be more explicit : Let us assume 
that a case comes under treatment in the early stage, the stage just 
prior to deformity. The simplest form of treatment is a snug plaster- 
of-Paris bandage from the upper third of the thigh to the lower third 
of the calf, applied over a snug-fitting stocking or over a simple cheese- 
cloth bandage. The plaster should not be made removable unless one 
desires to employ counter-irritation, which, by the way, is sometimes a 
very good adjunct to the treatment by fixation and rest. The patient 
should either be confined to a bed or a wheeled chair, or allowed to use 
axillary crutches with a high shoe or patten on the foot of the well side. 
Where there is much pain on one or the other side of the knee the 
Paquelin cautery should be employed two or three times a week. In 
this case a plaster splint may be made such as is shown in Fig. 343, 



Fig. 343. 




Plaster knee-splints. 



which represents a side and front view. This splint can be easily re- 
moved and reapplied, and is secured, as will be seen, by a lacing over 
shoe-hooks. Adhesive strips of plaster can be employed in place of 
shoe-hooks, or straps with buckles. 



352 



ORTHOPEDIC SURGERY. 



The plan just detailed can be made efficient throughout the entire 
course of the disease, assuming that the case has come under observation 
in the early stage. It can be employed even in later stages with great 
advantage. Other measures are needed, such as correction of deformity, 
the diiferent procedures for the treatment of abscess, arthrectomy, the 
removal of foci, etc. etc. 

A popular impression, which is shared to a great extent by the pro- 
fession as well, is that fixation of a limb in plaster of Paris or any 
splint or dressing which immobilizes is sure to result in ankylosis, and 
one, therefore, who may resort to the method just described will en- 
counter throughout the entire course a most obstinate ankylophobia in 
the parents, as well as in the physicians who may come in contact with 
the case. This one fact has within the last few years been most fully 
established — namely, the best -way to prevent ankjdosis is to secure the 
most perfect immobilization in a joint near which or in which disease 
exists. Time and again I have heard surgeons of large experience give 
advice like this in the consulting-room : " Put the limb in plaster, and 
let the patient get ankylosis as soon as possible." Ankylosis results 
from incomplete immobilization and poorly-fitting splints, because the 
inflammatory products that result from the trauma of muscular spasm 
and from use produce periarticular as well as intra-articular adhesions. 
I have myself on many occasions observed inflammatory products about 
a joint undergo resolution under absolute immobilization conjoined with 
rest. 

Inasmuch as many are not accustomed to the use of plaster, other forms 
of fixation may be mentioned, such as posterior splints of leather — an 
example of which can be seen in Fig. 344 — of wood, of steel bars on 
either side of the limb, joined at top and 
bottom by bands which partly encircle 
the limb and are secured in position by 
roller bandages. Such a brace is known 
at the hospital as the Knight knee-brace, 
and is a very serviceable splint. The 
various forms of traction apparatus, such 
as the Sayre splint and the various ones 
of the shops, which are largely figured 
in all the text-books, may be used if 
care is taken to apply them so that pro- 
tection is ample. The splint which has 
proven most valuable in my own hands 
is the Thomas knee-splint, which is 
sho%yn in Fig. 345. This is, in fact, an 
ischiatic crutch, and when supplemented 
by fixation of the joint really meets all 
the indications for an ideal treatment. 
The patten or high shoe should be at 
least three and a half inches in height. 
Four or four and a half is preferable, 
even if it be necessary to employ ankle- 
supports on the high shoe. Tlie late 
Mr. Thomas himself insisted always on a very high patten, for the rea 



Pig. 344. 



Fig. 345. 





Leather knee-splint 
(Marsh). 



as: 



Thomas's knee- 
splint. 



TUBEBCVLAB OSTITIS OF THE KNEE. 353 

son that the foot on the affected side would not touch the floor, and as 
the child grew there would be no danger of the splint growing too short 
between the dates for observation. A knee thus protected really requires 
very little attention. The parents can be easily instructed in the ordi- 
nary details of home-management. In private practice objection is often 
made to the height of the shoe, and to obviate this I have had the splint 
made extensible. In order to prevent the toe touching I have employed 
a pretty taut check-strap between the bars just back of the heel. This 
check may be of leather and broad enough to prevent the heel from rest- 
ing on top of it. The ordinary leather trough, as figured in the cut, was 
regarded as all-sufELcient by Mr. Thomas, because he bandaged the knee 
back into this trough and secured a very fair degree of immobilization. 
I have found plaster of Paris much more serviceable and much more 
reliable. 

Convalescing treatment, which should not even be suggested until 
after all inflammatory signs have disappeared from about the knee and 
until a small range of motion has been secured, is this same splint with 
the foot-piece cut off and the ends of the stems turned at right angles so 
as to make a caliper splint. These turned ends of the stems are insert- 
ed into a hole through the front part of the heel of the shoe. The high 
shoe is, of course, discarded now, and the patient is sufficiently protected 
against traumatic influences. 

In my analysis to which I have made reference (the paper was pub- 
lished in the American Journal of the Medical Sciences for October, 
1893) the very best results were obtained by the Thomas splint conjoined 
with fixation by plaster of Paris. 

The occurrence of abscess is not by any means a bar to the treatment 
now under discussion. On the contrary, the abscess cases are almost 
as easily managed as those in which abscess has never occurred. For 
instance, I find this paragraph in my r6sum6 : " By the protective plan 
where abscess occurred (19 cases), 16 had motion and 3 were ankylosed. 
Where abscess did not occur (18 cases) all had motion, none were anky- 
losed." 

The deformity can be corrected by various forms of apparatus by the 
simple use of plaster of Paris. A snug-fitting plaster bandage can be 
applied to a knee in a high degree of deformity. The patient can be 
allowed to walk about on a pair of axillary crutches. At the end of a 
fortnight the plaster can be removed and a little better position will be 
found — that is, less deformity ; plaster again applied, and so on until 
very nearly all deformity will have disappeared. This is rather a slow 
process, but is one that is safe, and in a certain proportion of cases efii- 
cient. An excellent method is weight and pulley in bed on a double 
inclined plane. I have seen acute-angled deformities overcome within 
a few weeks by this method, and with very little pain or discomfort 
attending the whole process of correction. The posterior splint of 
Knight is applicable to a certain number of cases. This splint, it must 
be understood, relies for its efficiency on the proper use of the roller 
bandage. 

The Billroth splint, which is very similar to the sector splint of the late 
Dr. Stillman, is about the best means for correcting the average deformity 
with which I am familiar, or it may be that I have used this to the exclu- 

VoL. II.— 23 



354 ORTHOPJEDIG SURGERY. 

sion of many others on account of its simplicity and general applicability. 
I shall take the liberty of presenting a quotation from a paper published 
in the Medical and Surgical Reporter for June 9, 1888 : "The method 
may be described as follows : Two fan-shaped pieces of tin or steel, each 
applied to an iron bar, are connected at the smaller expansion by a joint. 
One fan-shaped piece fits the outer surface of the thigh, the other the 
outer surface of the leg, the joint being at the knee, a similar instrument 
being applied to the inner side. The whole is of very simple construc- 
tion, and can be made by yourself or by any smith. The leg is then 
covered by a skin-fitting stocking or flannel bandage ; some turns are 
made around the limb with the plaster-of-Paris bandage ; then this in- 
strument is applied and covered with the plaster of Paris. The lower 
part of the patella, bordering on the ligamentum patellae, should be left 
exposed, not covered by the plaster. The bandage should be applied 
very thickly in the popliteal space. The limb should be put up in the 
position you find it, without any extension being made. While the cast 
on the leg is still damp take your knife and make a transverse section of 
it down to the skin through the popliteal space. This completes the first 
dressing. The patient should now be allowed to go home, and the cast 
to become completely hardened before you do anything further. After 
twenty-four hours, and from day to day — if necessary from week to 
week — you can proceed to straighten the limb with manual force by 
degrees, maintaining what you gain at each visit by inserting a piece of 
cork between the divided portions of the plaster cast in the popliteal 
space. A piece of adhesive plaster passing over the cork to the cast on 
either side will retain it in position." 

After the knee has been brought to about 175° it is difficult to eflfect 
further correction without the employment of more force than is usual, 
and my plan is to employ a solid plaster-of-Paris bandage at this period, 
making a little extra extension while the plaster is setting. The lirub, 
once straight, is very easily treated by the use of the Thomas knee- 
splint. 

The operations for the correction of deformity are manual force under 
an anaesthetic, division of hamstring tendons conjoined with manual 
force, osteotomy above the condyles, cuneiform osteotomy through the 
joint, and excision of the knee. The operations for the removal of 
disease are curetting ; gouging out of foci, which is known as partial 
arthrectomy ; complete arthrectomy ; which is removal of all the soft 
structures which go to make up the joint, supplemented by removal of 
any foci that may be within reach ; and excision of the knee. 

My experience in correcting deformity by means of mechanical ap- 
pliances under an anaesthetic inclines me to a preference for the correction 
under manual force, supplemented by division of the hamstring tendons 
subcytaneously. For one who prefers mechanical devices for this pur- 
pose the genuclasts of Bradford and of Goldthwait of Boston are spe- 
cially recommended. An illustration of the Bradford genuclast is fur- 
nished in Bradford and Lovett's work on Orthopcedic Surgery. The 
treatment of abscess is based upon the same principles as those depend- 
ing upon disease of the spine and disease of the hip. 

The indications for arthrectomy are not always clear, for the reason 
that extensive suppuration is often relieved by curetting and by the 



TUBERCULAR OSTITIS OF THE KNEE. 355 

proper protection of the joint. The advantages offered by arthrectomy 
when excision is contemplated are that the function of the joint may be 
retained or restored and that shortening of the limb will not result. In 
my own practice I very seldom have occasion to even recommend arth- 
rectomy, because of the uniformly good results which can be obtained 
in children, and because in adulte excision seems to me to offer certain 
advantages. 

Excision is done most frequently in adult patients, and the operation, 
when done thoroughly, gives a very useful limb. It is difficult to lay 
down any hard-and-fast rules for excision, but it is certainly a good 
operation to recommend for tubercular disease of the knee in adult 
patients or in patients who have passed the age of childhood, espe- 
cially if they belong to the poorer classes. Where one can afford the 
time and the expense of a prolonged course of mechanical treatment, 
and where the case is not complicated by severe pain or deep-seated 
suppuration, a successful result can be attained by efficient mechanical 
appliances. A case, however, which has had inadequate protection 
during the first year or two of the disease and has gone through various 
methods of treatment imperfectly carried out should really be treated by 
excision. There are in all large cities a great number of unsteady, 
painful knees in which disease has existed for many years, and where 
various futile efforts have been made to secure a useful limb. Such cases 
exist largely among the poor in the laboring classes, and it is idle to talk 
about treatment with apparatus. It is not necessary to wait for an 
abscess in such cases, but once the diagnosis is established and the con- 
ditions above stated found to exist, then the sooner the operation is done 
the better. 

Prognosis. — In children a good result can, in a large proportion of 
cases, be secured. By " good result " is meant a straight limb, very often 
a knee with the functions very nearly restored, arrest of all disease, no 
shortening, and little if any lameness. It is the exception to have short- 
ening in this disease where deformity has been prevented, or where it 
has been corrected early and a good position maintained until all symp- 
toms and signs have subsided. 

In the paper to which I have already made reference my analysis 
showed that motion was obtained more frequently in those treated by the 
protection plan. In 16 of the cases where abscess occurred there was, 
as final result, 90° of motion, while in those where abscess did not occur 
25 could be moved voluntarily over an arc of 90°. Relapses are not 
very frequent, and of all the cases, whether they recovered with motion 
or without, 150 out of the 300 presented subluxation of the tibia, 
against 48 where there was no subluxation. Only 2 of the whole 
number presented complete luxation. In 183 cases where the con- 
dition of the patella was noted, 124 gave a movable patella, while in 
59 there was no motion. Out of 227 cases analyzed so as to bring out 
the position of the limb, 15 got well with deformity at an angle under 
135°, and 141 presented an angle of deformity of not less than 165°. 
They were enabled, therefore, to walk with limbs practically straight 
and with scarcely an appreciable deformity : 71 of these could extend 
their limbs to an angle between 175° and 180°. These results, under- 
stand, are from cases treated by all methods except extensive operative 



356 OBTHOPMDIO SURGERY. 

procedures. By comparing the different methods, however, the protective 
treatment, which included rest as well, gave the largest percentage of 
good results, while the fixation came next, and the expectant gave the 
smallest percentage. 

Minor oe Non-tubbbculab Diseases of the Knee. 

1. Acute Arthritis of Infancy. 

The most important of these diseases is the acute arthritis of infancy. 
This has also been styled acute epiphysitis and acute osteomyelitis. It 
occurs in very early life, sometimes in a few weeks after birth, more 
frequently within the first year of life. It begins as an acute process, 
attended by marked constitutional disturbance, and soon resulting in 
extensive suppuration with great deformity. The diagnosis can be easily 
made by comparing these rapid changes with the changes which take 
place in a chronic tubercular ostitis. Again, the age of the patient is 
against a tubercular lesion. The treatment is surgical from the begin- 
ning. If hot fomentations and rest fail to give relief within the first 
week, then the abscess should be freely incised, its depth noted, any 
broken-down bone removed, and all the parts thoroughly drained. At 
the same time, the limb should be brought into normal position and 
retained by a firm dressing, and nothing has appeared quite so satisfactory 
to me as the plaster of Paris. Where such prompt measures are not 
adopted the case usually proceeds from bad to worse, and the end is 
either a fatal result or a flail joint which troubles the patient throughout 
life. I do want to emphasize, again and again, the necessity for prompt 
surgical measures. 

2. Periarthritis. 

Periarthritis is phlegmonous in childhood, while in adult life it is 
simply a subacute or chronic inflammation of the deeper structures sur- 
rounding the joint, and is associated frequently with rheumatism. The 
diagnostic points have been mentioned already in discussing the differ- 
ential diagnosis of tubercular ostitis, so that a repetition is unnecessary. 
The treatment, however, calls for rest when it is phlegmonous, with 
resort to the knife if resolution does not follow promptly ; while in 
adults, especially if it be rheumatic, motion should be enjoined. If 
adhesions have formed and a stiff" joint results, then attempts should be 
made to correct under an ansesthetic, at the same time preserving what^ 
ever motion is gained. This brings one to the discussion of ankylosis 
in general. Suffice it to say, that a joint that is very firmly ankylosed 
from periarticular adhesions is exceedingly rare. There are also intra- 
articular adhesions, which make a restoration of function exceedingly 
difficult. "Where osseous union between the patella and intercondyloid 
space is believed to exist I favor open incision and a separation of this 
union. The subsequent treatment is massage, the douche, and active 
and passive movements. 

3. Eheumatic Arthritis of Knee. 

Rheumatic arthritis is one of the most common affections of the knee 
in adult life. It frequently depends upon a trauma of some kind, and it 



MINOR OB NON-TUBERCULAR DISEASES OF THE KNEE. 357 

is only after the disease is developed that a rheumatic element is dis- 
covered. The diagnosis has already been under discussion. The treat- 
ment may be outlined in the following quotation, which I take from a 
paper recently published in the Denver Medical Times for January, 
1895 : " In summing up, therefore, the treatment of a chronic or sub- 
acute rheumatic knee, I would say that use in the early stage is good, 
but let the patient understand that the motion is not to be forced — that 
if he finds flexion beyond a certain range painful, let him avoid this test. 
For the night-pains hot fomentations are good. For pains that persist 
throughout the day the Paquelin cautery has, in my hands, proved most 
efficient. Where the traumatism induces an exacerbation, rest in a plaster- 
of-Paris splint for a few weeks is eminently proper, but on the subsidence 
of the pain the limb should be used up to the range of tolerance. The 
use of adhesive plaster has, in my hands, been of great service. The 
advantage, I think, which this has over the silk elastic knee-cap or any 
kind of knee-cap is that the pressure is made directly over the parts 
infiltrated, and does not completely encircle the limb, thus interfering 
with the return circulation and impairing more or less the tissues below, 
so that I seldom ever use an elastic knee-bandage in rheumatic knees. 
I sometimes use a canvas knee-bandage which is laced up along the inner 
side, and under which can be placed cotton-wool for more equable pres- 
sure. Where the ankle is involved as well I use a good deal the stock- 
inet bandage. My chief reliance, however, is in the brace, which is to 
be worn until complete convalescence is established." 

4. Internal Derangement or Knee. 

One of the most common internal derangements of the knee is a dis- 
placement, more or less complete, of the semilunar cartilage. This injury 
results from a sharp and sudden flexion of the knee with rotation inward 
or outward. Where the rotation is inward, the internal semilunar is 
subject to a sharp separation of some of its fibres of attachment, per- 
mitting a slight slipping or a complete slipping of the cartilage, which 
makes a dislocation of the same. Where the twist is external the exter- 
nal semilunar cartilage suffers in the same way. The pain is quite severe. 
The patient feels a slipping of some kind, and naturally either extends 
the limb or gets some one to extend it fully and make traction. This 
procedure often results in a replacement of the cartilage. If this could 
be followed, now, by protection to the parts for a reasonable length of 
time, say a fortnight, all acute symptoms would subside and the result 
would be perfect. But it is not usually thus followed by any protection ; 
the patient continues to use the limb, and an arthritis by contiguity is 
set up as a result of the repeated traumatisms. When the case comes 
under the care of the surgeon he usually finds a general arthritis, and it 
is difficult to detect the real starting-point of the lesion. A history will 
usually be afforded of subsequent slippings, and an examination, with 
this history, made with the knee flexed, will enable one to determine the 
ridge along the upper border of the head of the tibia, which ridge of the 
soft parts is caused by the projecting semilunar cartilage. 

The treatment, as has already been suggested, is protection to the 
parts, preferably in a plaster-of-Paris bandage, with the knee fully 



358 ORTHOPEDIC SUBGEBY. 

extended. The patient should use axillary crutches for two or three 
weeks, or even longer if the symptoms persist. A snug-fitting, plaster- 
of-Paris bandage, however, for two or three weeks in the majority of 
cases will be all that is necessary for such firm protection. On the 
removal of the plaster the external parts should be strapped well with 
strips of rubber plaster, and the patient should be cautioned against 
bending the knee until all symptoms have completely subsided. If the 
case is one of long standing and comes under the care of the surgeon 
during one of the relapses, then something more than the above precau- 
tions is necessary. In my own practice I have found a splint, such as 
has been described in the preceding pages in the treatment of rheumatic 
knees, most efficient. The range of motion is limited for a few months. 

The operation for removal of the cartilage or for exposing it and 
anchoring the torn edges by sutures has proven very successful in the 
hands of some surgeons, but as a general surgical procedure it is not 
usually recommended. At least, it ought not to be recommended until 
other measures have failed — measures such as have been already de- 
scribed. The operation itself is simple enough. One can easily reach 
the offending body, can expose the parts fully, and can suture the carti- 
lage to the head of the tibia by silkworm gut or even good sterilized 
catgut. One of the main contraindications for the operation is the ex- 
istence of other loose bodies in the knee complicating the displaced 
semilunar cartilage. 

Loose bodies in the knee, known as loose cartilages, may arise from 
hydrarthrosis or from acute attacks of rheumatism. These bodies can 
be easily felt and the diagnosis is not very difficult. 

The treatment is mechanical and operative. 

The chief form of mechanical appliance is an elastic bandage about 
the knee, or laced knee-cap, as it is called, which serves to fix the loose 
body in some one particular part of the joint where it is innocuous. 

The operation consists in crowding the cartilage toward the surface, 
where it can be felt directly under the skin — a free incision thereover, 
with enucleation of the body. This operation, simple as it may seem, is 
not always successful, but is sometimes attended with a pretty sharp 
attack of arthritis, followed by adhesions and fibrous ankylosis. It is 
one of the recognized operations, however, in surgery, and is to be per- 
formed under strict aseptic precautions by a surgeon who has had a 
reasonable degree of familiarity with joint surgery. 

5. BUESITIS. 

A not infrequent injury about the knee may be traced to an inflam- 
mation of the bursse. On page 349 injury to the bursse has been discussed 
in making differential diagnosis of ostitis of the knee. For diagnosis, 
then, one can refer to this section. 

The treatment involves a period of rest to the joint, accompanied with 
strapping of the bursa when not too acutely inflamed. If the latter be the 
case, hot fomentations are eminently satisfactory. The prepatellary bursa 
is the one most frequently affected, and is known as " housemaid's knee " 
or " devotional knee." Here we have often a good-sized tumor which 
requires tapping or excision. Generally tapping, with firm compress 



OSTITIS OF THE ANKLE. 359 

immediately following, is sufficient to effect a cure. In some instances, 
where the inflammatory area has extended not only about the joint, but 
into the joint, a posterior splint, or even a plaster-of-Paris bandage, is 
regarded as a valuable adjunct. Other bursas about the joint are not 
usually subjected to operations, because a knowledge of the existing 
conditions will enable one to adopt expectant measures for relief. 

6. Neurosis. 

For neurosis of the knee the same principles in treatment may be 
adopted which have been already outlined in the section on neurosis of 
the hip. (See page 345.) 

7. Charcot's Knee. 

For tabetic knee or Charcot's joint we really have little in the way 
of treatment. It is interesting simply from a diagnostic point of view, 
and curative measures are yet to be suggested for this extraordinary 
disease. 

Ostitis of the Ankle. ^^ 

The synonyms are — Caries of the ankle. Tuberculous ankle. Tuber- 
cular ostitis of the ankle, White swelling of the ankle. Chronic syno- 
vitis. The disease itself is characterized by impairment of motion, pain 
on use, reflex spasm, bony enlargement, destruction of bone, destruction 
of the joint-surfaces, abscess, and deformity generally. 

The etiology and pathology have already been discussed. It remains 
now to note the clinical history. 

Clinical History. — The invasion of this joint by disease is very 
similar to the invasion of other joints. The patient favors the foot in 
walking. One can easily recognize the ankle-limp. We have the cha- 
racteristic exacerbations following upon trauma — extra heat about the 
bony prominences, preferably the malleoli, sometimes the head of the 
astragalus, sometimes the scaphoid. The contour of the joint is soon 
changed, so that a comparative examination will enable one to detect 
filling up of normal depressions, exaggerations of bony prominences, 
atrophy of the calf, and increasing disability. Later we have abscess, 
which is attended usually with severe pain enormously aggravated by use. 
The abscess may be multiple, and the whole joint may be ultimately riddled 
with sinuses. The history of ostitis of the ankle differs a little from 
that of the knee and hip in that resolution in children is sure to follow, 
and that complete destruction of the joint and death from suppuration are 
the exceptions. It is a curious fact that the farther removed that a tuber- 
culous joint is from the centre of circulation the better result we may 
expect. In the ankle, for instance, a child may go through all the stages^ 
of this disease, extending over a period of from two to five years, may be 
subjected to various kinds of treatment irregularly carried out, and will, 
as a rule, make a good recovery — a recovery which enables the child to 
walk without lameness and to have very nearly normal use of the foot. 

Ostitis of the ankle as it affects adults is altogether a different dis- 
ease, and radical measures are much more frequently demanded. The 
course is by no means benign. It is difficult to secure adequate pro- 



360 ORTHOPMDIC SURGERY. 

tection to the ankle in an adult, and for this reason expectant treatment 
is, as a rule, unsatisfactory. 

Diagnosis. — A number of lesions about the ankle, such as periar- 
thritis, sprain, synovitis, teno-synovitis, imreduced subluxations, simulate 
ostitis of the ankle, but a careful comparative examination of the parts 
will enable one, as a rule, to detect localized areas of inflammation ; for 
example, over one or the other of the malleoli, over the bones of the 
tarsus ; reflex spasm, atrophy of the calf. These signs, taken in con- 
nection with a satisfactory history, enable one to differentiate this dis- 
ease from any that have been named. It is unnecessary, therefore, to 
go over the points in differential diagnosis. 

Treatment. — The management of a case depends largely upon the 
age at which the disease develops. If it occurs in a young child under 
four years of age, fixation of the foot in a skin-fitting plaster-of-Paris 
bandage, with strict injunctions against walking, will suffice to bring 
about a very satisfactory result. This treatment must extend over a 
period of twelve months at least. If abscesses have already formed, 
these may be aspirated, or, if the aspiration fails, incision may be made 
and foci of bone, which can be reached through the incisions, removed 
by the spoon. Fenestra can be cut in the plaster, so that immobilization 
can be continued, or the plaster itself may be cut down in front and 
made into a splint. In lieu of the plaster, wire or leather splints may 
be employed — anything, in fact, which secures adequate immobiliza- 
tion. If the child is over four years of age, or even over three in some 
instances where it is desirable to have the child walk, a splint may be 
employed very much like the Thomas knee-splint, with a patten or high 
shoe on the sound foot. The weight is thus transferred from the sole 
of the foot to the perineum, and the child will soon learn to walk about 
very comfortably. Where a light support, such as plaster or leather or 
wire cast, is not used to immobilize the foot, a sliding foot-plate should 
be applied to the Thomas knee-splint, near the lower end, and in that 
way the foot can be kept at right angles, thus affording all the pro- 
tection that is required. In older patients, adolescents and adults, im- 
mobilization supplemented by axillary crutches will give relief in a 
certain number of cases. Where, after a reasonable length of time, this 
treatment proves valueless, operative measures should be instituted, such 
as removal of the astragalus, excision of the joint, or even, in desperate 
cases, amputation. 

Such, in a general way, is the treatment for ostitis of the ankle. In 
children where abscesses form and burrow throughout the foot the man- 
agement is often exceedingly difficult. If one is familiar with the 
clinical history, the temptation to excise or partially excise is not great. 
If the abscesses are properly drained and if the foot is kept in good 
position, recovery in a large percentage of cases will take place, with a 
useful foot — a foot on which the patient can walk with very little lame- 
ness and without a support. It is interesting to note, too, that a child 
may suffer from numerous abscesses about the ankle, the suppuration 
may not only be extensive, but prolonged over a period of years, and 
still the liver and kidneys will not be involved in amyloid changes. 
One need not, therefore, fear amyloid degeneration in a case of ostitis 
of the ankle in a child. Exhaustion is exceptional too, yet the surgeon 



SPRAINS. 361 

must be prepared to follow up these sinuses from time to time, afford 
efficient drainage, attend to the general health, encourage an out-of-door 
life, avoid too long confinement in hospitals, and even excise or ampu- 
tate if the case should seem to demand so radical a procedure. In a 
word, then, a case must be managed on sound surgical principles. The 
surgeon must not take fright at the occurrence of numerous abscesses 
and sinuses, but must rely very largely upon the recuperative powers of 
nature. Excision of the ankle may be better studied in other sections 
of this work, and for this reason I have omitted any extensive reference 
to it in this connection. 

Sprains. 

The term " sprain" is used to designate a sudden rupture of the soft 
tissues immediately surrounding a joint, a stretching of these tissues 
without necessarily a rupture of any of the parts. The lesion, however, 
is followed by swelling, pain, ecchymosis, disability of the joint, and 
sometimes a deformity. A sprain varies in degree, and leaves one at a 
loss sometimes to decide just how much injury has been wrought. It 
is common to speak of rupture of ligaments or separation of the liga- 
mentous attachments, but when such occurs the injury is very severe. 
Indeed, it is difficult to make out just whether a ligament is ruptured 
or not. More frequently some fibres of the tendon are torn in two or 
the bruising takes place about the insertion of the ligaments or tendons, 
which gives rise to the signs above mentioned. Ordinarily, acute sprains 
do not come within the scope of orthopsedic surgery. A disability of 
the joint which has resulted from a sprain weeks or months previously 
often comes under the care of the orthopsedic surgeon, because of this 
disability and because a cure has not been effected. The mode of pro- 
duction of this injury and the history of the symptoms and signs for the 
first few days are quite familiar to all medical men, hence details are 
unnecessary. 

Diagnosis. — The diagnosis is very important, and it is difficult at 
times to differentiate a sprain from a fracture or a subluxation. The 
foot may be so distorted that one of the tarsal bones may project unduly 
and give rise to the suspicion of a dislocation. Again, the swelling 
about the malleoli may be so great that it is very difficult, by reason of 
the extreme tenderness associated with this swelling, to get a satisfactory 
examination. Ordinarily, however, the diagnosis is simple enough. A 
comparative examination of the ankles can be made, the functions of 
the joint tested, and a little manipulation is all that is necessary to detect 
crepitation. If it is impossible to get a satisfactory test by manipulation, 
then it would be better to treat the case as a fracture for a few days 
until the swelling shall have subsided, when the examination can be 
made quite easily. 

Treatment. — In an acute sprain, or one that is seen even Avithin a 
week or ten days after the injury, the plan which I have adopted with 
exceedingly gratifying results is the Cotterell dressing. I have already 
published two articles on this subject, the last one of which, in the New 
York Medical Journal for February 16, 1895, was fully illustrated. The 
details are as follows : After making the examination, employ massage 
for five or ten minutes with the foot well elevated. Next apply strips 



362 ORTHOPEDIC SUBOEBY. 

of rubber plaster, about an inch in width and from twelve to eighteen 
inches in length, over the part sprained, beginning back of the injury. 
Aim to leave the part of the foot not affected as well uncovered as pos- 
sible, but reinforce well as the strips are applied under the malleolus or 
malleoli. The first strip for a sprain of the external malleolus is applied, 
beginning just above the ankle on the unaffected side of the foot, and 
ending on the affected side about half the way up the calf. This strip 
is usually alongside the tendo Achillis and makes firm support under the 
heel. The second strip starts on the inner side of the unaffected part of 
the foot, near the ball of the toe, comes around over the back of the heel, 
and ends about the base of the little toe. It crosses the first one just 
above the border of the heel. The third strip overlaps the first halfway, 
the fourth the second, and so on until the part sprained is fully covered 
by this criss-cross strapping. A cheese-cloth bandage is applied, more 
with the idea of securing close adhesion of the plaster, and is removed 
within twenty-four hours. As soon as the dressing is completed the 
stocking and boot should be applied. The patient is now ready to begin 
walking, and this should be insisted upon in the presence of the surgeon. 
Direct him, for instance, to walk about the room eight or ten times. At 
first strong objections are offered, but after two or three turns it is 
asserted that walking becomes much more easy, and by the time the task 
is completed there will be very little lameness or disability. While it is 
undesirable to insist on too much walking for the next few days, it is 
essential that the patient should walk as much as it is necessary for him 
to walk— that is, attend to his business or any duties that require a mod- 
erate amount of walking. At the end of a week it is well to remove the 
strips and reapply in the same manner as above. Two or three such 
dressings suffice to complete the cure. 

In old sprains a support must be worn for a much longer period, and 
where adhesions have already formed it has seemed to me that a plan 
which was recommended by the late R. O. Cowling, M. D., of Louisville, 
Kentucky, should be adopted before the strips are applied — namely, 
under primary anaesthesia move the foot about, break up the adhesions — 
produce, in fact, an acute sprain — and then treat this by the adhesive 
strips. Where one desires to raise the side of the foot a little, the sole 
of the shoe may be built up on that side from a quarter to three-eighths 
of an inch. 

I have refrained from presenting the ordinary treatment by fomenta- 
tions, plaster bandage, etc., because I found these methods very unsatis- 
factory, and because these methods are fully illustrated in all the text- 
books of surgery. Incidentally, I have found adhesive strips very useful 
in sprains about the knee and other joints. Where the spinal column 
has been sprained, I have also used the adhesive strips with decided 
advantage. 

Diseases op the Joints op the Upper Extremity. 

The Shoulder. 

Tubercular ostitis of the shoulder is rare in childhood, and still less 
frequently observed in adults. The lesions which are met most fre- 
quently are the results of old sprains of the shoulder, rheumatic periar- 



DISEASES OF THE JOINTS OF THE UPPER EXTREMITY. 363 

thritis, and luxations. The diseases which the orthopaedic surgeon is 
called upon to treat are ostitis of the shoulder, fibrous periarthritis the 
result of rheumatism or exposure, and congenital luxations and sublux- 
ations. 

Ostitis is characterized by very nearly the same signs that one finds 
in ostitis of the hip or knee, such as reflex spasm, atrophy, limitation of 
movements, pain on use, extra heat. With a knowledge of these signs 
and symptoms diagnosis is comparatively easy. One naturally looks for 
an injury in getting the history, but if one fails to get a satisfactory ex- 
planation of the symptoms by reason of some trivial injury, it is fair to 
assume that an ostitis presents for consideration. 

In the way of treatment it has for a long time been regarded as un- 
necessary to employ apparatus, for the reason that the weight of the limb 
itself is sufficient to produce the necessary amount of traction, and in this 
way bring about a cure ; but in my own experience I have found the 
weight of the limb very unsatisfactory as a means of traction. Further- 
more, the patient, who is usually a child, does not know enough to make 
use of the weight of the limb, and it is difficult to have any instructions 
bearing upon this subject carried out. The use of the shoulder is gen- 
erally encouraged by some members of the family or by the family 
physician, so that the results are altogether disheartening. From a very 
extended experience I am convinced that traction apparatus should be 
employed if one expects to get a useful joint. It is comparatively easy 
to use a traction apparatus at the shoulder-joint and still have the use of 
the forearm. A leather-padded crutch-piece will rest in the axilla. To 
this a stem passing down the inner side of the arm, with rack and pinion, 
gives one an opportunity to employ as much traction as is desirable. 

In cases of long standing, where abscess has formed, protection 
may still be employed with advantage, but the facility with which one 
can reach the focus of bone by a small incision is very encouraging for 
operative interference. An incision in front of the upper end of the 
humerus, just below the joint, down through the periosteum, should be 
made, and the periosteum dissected on either side about halfway around 
the bone. A drill now can be inserted into the bone, up through the 
epiphysis, the opening enlarged, and the entire head of the bone be removed 
by a Volkmann spoon, leaving the articular surface intact. At the same 
time, what adhesions exist may be broken up, the arm put at rest, and 
the wound treated either by drainage or by closure as one feels confident 
of his ability to remove every particle of disease. In the ostitis of 
adults, where suppuration has occurred and where extensive adhesion 
exists, I certainly favor excision. Indeed, the results of excision of the 
shoulder-joint are so satisfactory that the temptation to excise early is 
verj' great. In children, however, the growth of the bone by excision 
is interfered with, and hence the partial operation I have just described 
is more desirable. 

In the rheumatic periarthritis of the shoulder, where the adhesions 
are slight and where the range of motion is only about one-half re- 
stricted, it is certainly better to break up these adhesions under an anses- 
thetic. The early use of the arm after the operation, say within two or 
three days, is necessary to secure the best result. Many of these cases, 
under the ordinary treatment of passive motion, massage, and active 



364 



obthopjEjdic surgery. 



exercises, make very slow progress, the patient suffers a great deal, and 
the final result is often a stiffish, painful joint. Where much inflam- 
mation exists around the joint I have employed with moderate success 
strapping of the joint and rest for a few weeks. After an improvement 
has been noted, then passive motion under an anaesthetic is called for. 
For the painful conditions which exist about the shoulder the Paquelin 
cautery, in my hands, has proved very efficient. 

In the congenital deformities of the shoulder, after many failures 
with the usual methods of making traction, employing passive move- 
ments with or without an anaesthetic, electricity, etc. etc., I have come 
to the conclusion that it would be better to cut down upon the joint and 
aim to replace the head of the bone in the glenoid cavity — failing in this,, 
to excise it. 

The Elbow. 

Tubercular ostitis of the elbow is occasionally met with. It is 
more frequent in children than in adults, and is often mistaken for the 
displacements of bone resulting from fracture. For the reason that 
serious results may follow very slight injuries at the elbow-joint it is 
difficult to rule out trauma as an exciting cause. If one is careful to get 
the history and makes a thorough examination of the elbow by comparing^ 

the salient points with those of 
Fig. 346. the other elbow, it is not difficult 

to make a diagnosis. In frac- 
tures of the condyles or epi- 
condyles, or even transverse 
fractures through the epiph- 
ysis, we have bony deposits re- 
sulting from unsuccessful efforts 
at reduction, and even in the 
successful cases we have often 
callus thrown out, which gives 
rise to many of the signs of an 
ostitis, such as bony enlarge- 
ment, irregularity, impairment 
of function, pain on motion, 
extra heat, etc. Reflex spasm, 
a sign which is so valuable in 
diagnosis of other joints in the 
body, does not serve us a very 
good purpose where this joint 
is affected, because it is difficult 
to distinguish reflex spasm from 
the spasm of pain on motion and 
the patient's own resistance. A 
very good illustration of the 
appearance of an elbow which 
is the seat of ostitis is shown in 
Fig. 346. The degrees of ostitis 
of the elbow are almost identical with those of ostitis affecting the other 
joints : first, the stage without any appreciable deformity ; later still, 




Ostitis of elbow. 



DISEASES OF THE JOINTS OF THE UPPER EXTREMITY. 365 

the stage of deformity with abscess; subsequently, the third stage of 
shortening and displacement. 

The treatment is rest to the parts over a long period of time, mainte- 
nance of the limb in good position, aspiration or incision of abscesses as 
indications present ; later still, if the suppuration persists, partial arthrec- 
tomy and excision. Excision is certainly a very satisfactory operation 
in the elbow-joint, and yields most gratifying results. 

Deformities of the elbow which result from fracture and displacement 
may be treated by eiforts at removing the displaced fragments, whether 
by passive movements under an anaesthetic or by incision upon the parts 
and removal with the chisel. A number of deformed elbows with callus 
interfering with flexion may be treated by repeated efibrts at flexion and 
retention in plaster of Paris for a week or ten days after each minor 
operation. From a rather extended experience in the management of 
such cases I am satisfied that this procedure should be adopted before 
attempts are made to remove the bone by the chisel. 

The Weist. 

Ostitis of the wrist with the consequent deformity certainly comes 
within the scope of orthopaedic surgery. The principles which govern the 
treatment of ostitis of other joints are equally applicable here, and the 
foci of disease themselves can be the more easily reached if operative 
interference is required. These principles have been presented so fully 
in the preceding sections that it is unnecessary to repeat them. 



ANEURYSM. 

By lewis a. STIMSON, M. D. 



The word " aneurysm," derived from a Greek word signifying dila- 
tation, has in the main preserved what appears to have been its primary 
signification — that of a hollow tumor whose cavity communicates more 
or less freely with the lumen of an artery, and into which, consequently, 
blood passes more or less freely from the artery. As clinical experience 
has increased, and facts ascertained upon the autopsy-table and in the 
laboratory have multiplied, the application of the term has been so 
greatly widened that it now includes arterial and even venous and 
capillary changes that have little or nothing in common with those that 
were primarily associated with it, and which cannot be included with 
them in a single definition. Nevertheless, excluding, on the one hand, 
certain pathological conditions known by specific titles, such as cirsoid 
aneurysm, aneurysm by anastomosis, dissecting aneurysm, and certain 
forms of arterio-venous aneurysm, and, on the other hand, certain 
changes too slight or too deeply situated to give any clinical symptoms, 
the term in its surgical acceptance indicates a condition that is perfectly 
well defined clinically and pathologically — that of an abnormal, local, 
circumscribed enlargement of the lumen of an artery with production 
of a (usually) pulsating tumor. This enlargement may have been pro- 
duced gradually by the progressive stretching and yielding of the coats 
of the artery, or abruptly by the tearing or cutting of the wall of the 
artery, followed by the immediate escape of the arterial blood into the 
surrounding tissues, and the gradual formation out of the adjoining con- 
nective tissue of a circumscribed wall or sac continuous with the wall of 
the artery at the margin of the opening. The size and shape of the 
enlargement and its topographical relations to the artery also vary 
greatly, and out of these varied elements and the shifting views and 
theories that have been held concerning anatomical details and pathogeny 
has arisen a nomenclature that is now needlessly complicated and but 
ill adapted to the subject. 

One of the earliest groupings was into so-called " true " and "false " 
aneurysms, including under the former term those aneurysms in which 
the continuity of all three coats of the artery was preserved throughout 
the dilated area, and under the latter term those in which the continuity 
of one or two of the coats was interrupted ; and according as one or 
another of the three coats was thought to be absent varieties were 
described which we now know could have had no existence save in the 
imagination or the incorrect observations of the writers. Apart from 
the inappropriateness of applying the term "false" to the common 
typical form of a disease, it can now be said that the so-called " true " 
aneurysm, one in which all three arterial coats are present in all portions 

367 



368 ANEURYSM. 

of the wall, is not only very rare, but also that it exists only in the form 
of small irregularities in the wall of the aorta that are unrecognizable 
during life, and in certain moderate uniform dilatations of the large arteries 
(part of the so-called " fusiform " aneurysms) that give rise to few or no 
symptoms and are not amenable to surgical treatment. Most of these 
conditions have only a pathological, and no clinical or therapeutic, in- 
terest, and would be more fittingly grouped under the term arteriectasis. 

i^.nother condition upon which opinions have been divided, and of 
which the nomenclature has become greatly complicated, is that following 
a wound or rupture of an artery with free escape of its blood into the 
surrounding tissues. Among the terms in use are traumatic aneurymi, 
ruptured artery, diffuse aneurysm, primary aneurysmal hcematom-a (when 
it follows the rupture of an artery), or secondary aneurysmal hoematoma 
(when it follows the rupture of an aneurysm). The difficulty is ia part 
an academical one — one of definition ; and in part it arises from varying 
anatomical conditions that depend upon the length of time that has 
elapsed in a given case since the rupture took place. When the con- 
dition is a recent one the anatomical conditions, the symptoms, and in 
most cases the treatment, are those of a wound of an artery, and are 
here described under that head ; but in the older cases the conditions, 
symptoms, and treatment are essentially those of a spontaneous aneurysm, 
and will here be treated in connection with it. It must be borne in 
mind that aneurysms consecutive to a partial rupture of an artery — 
rupture of only one or two of its coats without an immediate escape of 
blood into the surrounding tissues — are included not among the trau- 
matic, but among the spontaneous, aneurysms ; indeed, it is rather 
widely believed that many, if not most, of the common aneurysms of 
the limbs are due more or less directly to partial rupture of the wall by 
overstretching of the artery where it crosses a joint or by bruising in its 
passa,ge through a tendinous expansion. Such injuries and the resultant 
conditions are of course "traumatic," but custom limits the term to 
those in which the rupture has presumably been sudden and complete. 

We have, then, to describe — 

1. The common circumscribed aneurysm, including the so-called 
" true " and " false " aneurysms, traumatic aneurysm, ruptured or diffuse 
aneurysm, and fusiform aneurysm or aneurysmal dilatation ; 

2. Dissecting aneurysm ; 

3. Arterio- venous aneurysm, with its two varieties — varicose aneurysm 
and aneurysmal varix ; 

4. Cirsoid aneurysm. 

1. The Common Oiecumsceibed Aneurysm. 

This affection appears to be much more common in some countries 
than in others, England being thought to have more in proportion to 
population than any other country. Dr. Eldridge ^ states that Europeans 
dwelling in Japan are affected with thoracic aneurysm to an extent very 
largely in excess of the proportions observed in any other country. The 
relative frequency in New York is indicated by the following statistics, 
taken from the reports of the New York Hospital for the years 1888- 
^ New York Medical Jom-rwl, February 10, 1894. 



THE COMMON CIRCVMSCBIBED ANEURYSM. 



369 



Fig. 347. 






92 : Of 22,197 patients admitted to the hospital during those five years, 
55 were affected with aneurysm, divided as follows among the different 
arteries : aorta, 37 ; innominate, 3 ; femoral, 6 ; radial, 3 ; brachial, 1 ; 
and 5 cirsoid aneurysms. Of the 37 aneurysms of the aorta, 32 were 
in males, 5 in females ; of the 3 of the innomi- 
nate, 2 were in males, 1 in a female ; all the 
others were in males. Other statistics, com- 
prising a much larger number of cases, show the 
same predominance in males, and that the aorta, 
and mainly the thoracic portion, is much more 
frequently affected than any other artery. Such 
statistics include, in the main, only those cases 
that come directly under treatment, and but rela- 
tively few of the rather numerous aneurysms of 
the small arteries of the brain and of those in the 
walls of phthisical cavities in the lungs that are 
found post-mortem. So far as those aneurysms 
are concerned which are observed clinically, they 
involve the principal arteries in about the follow- 
ing order of frequency : First, the thoracic aorta 
(almost exclusively in its arch), then the popliteal 
and femoral, abdominal aorta, carotid and sub- 
clavian. The relative frequency of innominate 
aneurysm cannot easily be determined, for the 
differential diagnosis from aneurysm of the arch 
of the aorta is often impossible during life. 

Aneurysm is distinctly a disease of middle 
life, the great majority of cases occurring between 
the ages of thirty and sixty, or even thirty and 
fifty, years. Crisp's collection of 505 cases con- 
tained only one below the age of ten years, 5 
between ten and twenty, and 16 above the age 
of sixty years. I have seen one case at the age 
of seven years, a delicate girl who had a large 
aneurysm of the right common and external iliac 
and a small one of the left femoral. 

Aneurysms are usually single; occasionally 
two, three, or more coexist, and Pelletan reported 
a case in which 63 were found. A very few rare 
cases of multiple aneurysms of the smaller 
arteries have been described in detail by several 
writers, but under different names. Kussmaul 
and Maier ^ used the name periarteritis nodosa., 
and traced a connection between the affection 
and Bright's disease and progressive general mus- 
cular atrophy. Meyer ^ used the same name with 

the alternate "multiple aneurysms of the medium-sized andsnialler 
arteries;" and Eppinger^ gave them the name "congenital," to indicate. 




'ff 






X,. 



\ 



Periarteritis nodosa, or con- 
genital aneurysms of a 
small artery of the mesen- 
tery (Eppinger). 



* Anh.. fiir klin. Med., vol. i. p. 484. ' Vlrchoii/ 

^ Arch, fur klin. Chir., 1887, vol. xxxv., Appendix, p. 42. 
Vol. II.— 24 



I Arehiv, vol. Ixxiv. p. 277. 



370 ANEURYSM. 

not that they exist at birth, but that the condition of the arterial wall 
which favors their production does. 

Etiology. — The immediate cause of the production of an aneurysm is 
found in the loss of the equilibrium between the distending action of the 
intra-arterial pressure and the resistance of the arterial wall, by which 
the former becomes predominant. This loss of equilibrium is commonly 
due to a diminution of the ability of the arterial wall to resist the normal 
blood-pressure, and only occasionally, if at all, to a temporary sudden 
increase of the latter. A number of cases have been reported in which 
the presence of an aneurysm has been noted immediately after the patient 
has experienced some strong emotion or made a violent muscular eflFort. 
Thus, Holmes ^ quotes two cases in which aneurysm of the abdominal 
aorta followed immediately upon the patient receiving sentence for a 
criminal offence. 

The predisposing causes are general and local. Among the general 
causes are included those diseases, constitutional peculiarities, and habits 
which tend to diminish the elasticity and power of resistance of the arte- 
rial walls, such as syphilis, gout and rheumatism, and the prolonged 
habitual use of alcoholic beverages. Of these, the agency of gout, rheu- 
matism, and alcohol appears to have been satisfactorily established through 
their effect in producing the changes known as atheroma and endarteritis ; 
but the agency of syphilis is in doubt, both because clinical statistics do 
not support it, and because the arterial changes due to the disease are 
commonly manifested in the smaller arteries, where aneurysm is less 
frequent, and not in the aorta, where aneurysm is most frequent. 

Among the local causes more or less certainly determined are anatomi- 
cal peculiarities of the artery involved, such as its bifurcation, its change 
of direction, local alteration of the wall by disease, pressure, or an em- 
bolus, and injury of the wall by some form of external violence. The 
relative frequency of aneurysm of the common carotid at its upper end, 
where it divides into the external and internal carotid, is the only fact 
that can be quoted in support of the theory that the bifurcation of an 
artery is a condition favorable to the development of an aneurysm in its 
immediate neighborhood, and no satisfactory mechanical explanation of 
such alleged influence has been given. The influence of a change in the 
direction of an artery is thought to be shown by the relative frequency 
of aneurysm in the arch of the aorta, and the explanation is sought in 
the obstruction thereby offered to the flow of the blood through the vessel, 
and the consequent increase of the intra-arterial pressure at the points 
more directly impinged upon by the stream. As the same anatomical 
conditions exist in all individuals, while aneurysms exist in but few, it 
seems improper to speak of them as causative : some antecedent diminu- 
tion in the strength of the artery is clearly necessary, and the anatomical 
condition can be causative only in the sense that by increasing the intra- 
arterial pressure at that point (if it does) less diminution of resistance is 
then required than at others. 

A local change in one or more of the coats of the artery as the result 
of disease that diminishes its elasticity and strength undoubtedly pre- 
cedes the formation of all the small "true" aneurysms and of most 
others. This factor in the pathogenesis of aneurysms has long been 
' Holmes, Syst. of Surgery, Am. ed., vol. ii. p. 319. 



THE COMMON CIRCUMSCRIBED ANEURYSM. 



371 



positively known in connection with certain rarer forms of disease, acute 
or chronic, and has long been suspected in all except those in which 
sudden partial rupture of one or more coats by mechanical violence was 
the cause. Endarteritis, mesarteritis, and atheroma are the conditions 
precedent thought to exist in most cases ; but the fact that they are rela- 
tively frequent, wliile aneurysm is rare, that they are most common and 
extensive in advanced life, while aneurysm is a disease of middle life, 
and that they are found almost as frequently in women as in men, while 
aneurysm is much more frequent in men than in women, show that their 
predisposing influence cannot be very great and that some other im- 
portant cause must coexist. Probably the causative influence of these 
aifections is much greater in the aorta and its large branches than in 
the other portions of the arterial system. Large atheromatous arteries 
are frequently irregularly dilated and tortuous, and atheromatous degen- 
eration is habitually found in the old, and is often widespread and of 
long standing, and yet the vessels thus affected show little or no evidence 
of any tendency to the local circumscribed dilatation which constitutes 
aneurysm. In some cases a -p, „.„ 

cheesy atheromatous focus in . - 

the wall of an artery opens 
and discharges itself into the 
vessel, and the blood entering 
into the cavity distends it and 
forms a sacculated aneurysm, 
or works its way along be- 
tween the coats to break 
through again into the lumen 
of the vessel at a more or 
less distant point (dissecting 
aneurysm) ; but such cases 
are rare. 




■Am. 



Suppurative disease invad- 
ing the wall of an artery from 
an adjoining abscess is claimed 
to have led to the formation of 
an aneurysm ; but it seems 
more probable that in the few 
cases cited the artery has been 
perforated by the ulceration 
before the weakening of its 
wall has had time to end in an 

actual aneurysm, and the blood Mycotic-emboUc aneurysm of a small artery of the pia 

has then poured into the ab- 
scess through the opening and given it the appearance of an aneurysm. 

The effect of local inflammatory processes in the arterial wall due to 
microbic infection has been studied very carefully and in great detail by 
Eppinger,' using for the purpose specimens of infection of the wall from 
within by emboli coming from cardiac valvular vegetations due to endo- 
carditis, and specimens of infection from without by the tubercle bacillus 
in the small arteries of the walls of the pulmonary cavities. In connec- 
lEppinger, Arch, fur Urn. Chir., vol. xxxv.. 1887, Appendix. 



372 



ANEURYSM. 



tion with the investigation he also examined several special forms of 
aneurysms produced in horses by the presence and growth of the para- 
sitic worm strongylus armatus. In the first group of cases he found at 
the point where the infected embolus lodges (usually at the origin of a 
small arteriole of the pia) an acute exudative inflammatory process which 
involved all the coats, destroyed the tissue-elements, and brought about 
rupture of the intima and the elastic layer : this rupture of the intima 
and elastic layer appears to be the essential preliminary to the formation 
of the aneurysm, the wall of which is formed by the adventitia and, in 
very small aneurysms, by part of the niedia ; the increase of the aneurysm 
is associated with recurrent acute inflammatory processes in and about 
the media in the neighborhood of the opening. 

In the second group of cases, the small aneurysms of tubercular cav- 
ities in the lung, he found the inflammatory processes extending from the 
wall of the cavity, successively invading the coats of the artery from 
without, and followed by tuberculization. The formation and caseation 



Pig. 349. 




Healed partial rupture of ascending aorta, with subsequent formation of aneurysm • 
an, aneurysm (Eppinger). 

of the tubercles produced rupture of the difi'erent elastic layers, and then, 
if the lumen of the artery had not been obliterated by the thickened 
intima and a thrombus formed upon it, the intima was pressed outward 
into the gap created by the rupture of the outer coats, and thus the 
aneurysm was formed. Similar observations were previously made by 
Meyer.^ 

The study of both forms shows that whether the change in the wall 
of the artery involves its layers successively from within outward or from 
without inward, the aneurysm does not form until after the elastic bun- 
dles within the media have been dissociated and the elastic layer on its 

'■Arch, de Phys., 1880. 



THE COMMON CIRCUMSCRIBED ANEURYSM. 



373 



inner side ruptured. They indicate, therefore, that the media and the 
inner elastica offer the principal resistance to the dilatation of an artery, 
and that their rupture or their degeneration precedes the beginning of an 
aneurysm. This importance of the media has long been believed in on 
theoretical grounds, and its degeneration or its mechanical rupture has 
long been thought to be the necessary preliminary to the formation of an 
aneurysm. 

Mechanical causes (excluding sudden complete division of all the coats) 
are seen in the cases in which an aneurysm has formed after the violent 
stretching of an artery by which its middle or middle and inner coats 
have presumably been torn, or after prolonged compression of an artery 
to cure an aneurysm at a lower point, or where an exostosis has pressed 
upon an artery. In the cases in which an aneurysm has formed at the 
point where a ligature has been applied to the artery we may assume 
that the reparative process has not been complete, and that the arterial 
cicatrix has yielded rather than the adjoining portion of the wall. An 
exceptional instance of the effect of pressure is the case reported by 
Castle, in which an aneurysm of the palatine artery appeared to have 
been caused by the pressure of a dental plate. 

Pathological Anatomy. — We have to consider the sac and its con- 
tents and the changes produced in adjoining tissues by its presence and 
growth. 

The aneurysm may be a more or less regularly ovoid dilatation of a 
portion of an artery continuous at each end with it (fusiform aneurysm), 
or it may be an eccentric pouch situated beside the artery and commu- 
nicating with it by a lateral opening 
of greater or less size (sacculated an- 
eurysm). This sac may be uniformly 
rounded, or may present one or more 
subordinate pouches due to its uneven 
dilatation or to rupture ; it may vary 
in size from a diameter of a fraction 
of an inch to that of several inches. 
It is ordinarily a complete, well-de- 
fined membrane composed of the con- 
densed and thickened connective tis- 
sue of the space through which its 
expansion has forced it, mingled in 
some cases with more or less of the 
original coats of the artery, according 
to its size or shape. Thus, in an- 
eurysms in which the dilatation in- 
volves the entire circumference of the 
vessel for a considerable length, por- 
tions of the middle coat may be found 
at various points in the sac more 
or less widely separated from one 
another and degenerated : the lining membrane resembles in gross 
appearance the intima, and probably also contains portions of it. In 
the sacculated form of aneurysm the intima and media of the artery end 
abruptly at the edge of the opening, the neck of the sac ; the intima of 



Fig. 350. 




Carotid aneurysm; arte: 

the oriflee-(Scarpa). 



laid open to show 



374 ANEURYSM. 

the artery is continuous with a membrane of new formation that closely 
resembles it, but contains no elastic tissue, lines the inner surface of the 
sac, and often extends, by its endothelial layer, over blood-clots that 
have been deposited upon the wall. The adventitia of the artery is 
directly continuous with the condensed connective tissue that constitutes 
the main part of the sac. These anatomical conditions are the same even 
in purely " traumatic " aneurysms, in which the wall of the artery has 
been completely divided and the sac has been formed by condensation 
of the connective tissue crowded back by the escaping blood. 

According to Thoma,i in the small " true " and " mixed " aneurysms 
of the aorta the sac is composed of all three coats of the artery, of which 
the intima and adventitia are increased and thickened by connective 
tissue, while the media is thinned and in places lost. Coarse ruptures 
of any of the coats are wholly absent, and he suggests the name of dila- 
tation aneurysm (or aneurysm per dilatationem) as descriptive of the 
condition and mode of formation. He says the intima shows connective- 
tissue thickening, often with hyaline degeneration, calcification, and 
atheroma in the new tissue. The media is notably thinned, correspond- 
ing to the stretching, and in some places of greater distention it disap- 
pears, while the intima and adventitia remain unbroken. The primary 
change appears to be an arterio-sclerosis ; then come the stretching and 
thinning ; then a fibrous mesarteritis. In the larger aneurysms the con- 
nective tissue of this last process becomes very predominant. Then 
come hyaline degeneration, calcification, and atheroma. The adventitia 
is thickened, resembling cicatricial tissue (periarteritis). In the larger, 
ordinary aneurysms (for which he suggests the name rupture aneurysm) 
the media is ruptured ; a new intima is formed, composed of connective 
tissue without elastic elements, and apparently having an endothelial 
lining derived by extension from that of the adjoining intima of the 
artery ; the adventitia thickens and stretches. When perforation occurs 
it seems to be the result usually not of necrosis, but of thinning by 
stretching. The adjoining parts are more or less involved in the peri- 
arteritis, and the nerves and numerous Pacinian bodies (about the aorta) 
are compressed : this perhaps accounts for the pain. 

The contents of the sac are liquid and clotted blood and layers of fibrin 
in varying proportions. Almost all sacculated aneurysms show pale tough 
layers of fibrin adherent to the wall, sometimes in such quantity as almost 
to obliterate the cavity. This fibrin, the "active clots" of Broca, is 
arranged in layers, of which the most external, those adjoining the wall, 
are the oldest; they are opaque, gray, with darker, reddish streakings 
parallel to the surface. They are evidently formed by slow deposition 
from the blood, and the darker stains are due to slight clotting of the 
blood upon their surface or after it has made its way into their interior 
along lines of cleavage. The soft black clots, Broca's " passive clots," 
are formed by the rapid coagulation of the blood in bulk, the ordinary 
clotting, such as occurs when blood is withdrawn from the body. Neither 
variety has any structural or vital connection with the wall ; each simply 
rests upon it, and is not bound to it by any permeating tissue or blood- 
vessels of new formation. The few cells that are sometimes found within 
them are the remains of the leucocytes of the blood. The edges of the 
' Thoma, Virch. Arch., vol. cxi. 



THE COMMON CIRCUMSCRIBED ANEURYSM. 



375 



Fig. 351. 



white fibrinous clots are often snugly bound down in places by the ex- 
tension over them and the adjoining surface of the clot of the endothelium 
lining the uncovered part of the sac. As the sac increases in size the 
fibrinous clots become partly detached or broken, and then when addi- 
tional deposition takes place the new layers are not all parallel to the old 
ones, but meet and cross them at varying angles that clearly indicate the 
mode of increase. 

The mode of formation of the laminated (" active") clot has been the 
subject of much discussion, and various theories have been advanced in 
explanation of it. One of the early theories, 
that it was not deposited from the blood, but 
was plastic lymph, an exudate from the wall of 
the sac, is in hopeless discordance with the 
observed facts, which clearly indicate that the 
oldest layers are those that lie nearest to the 
wall. Another, advanced by Richet\ and 
adopted by Holmes^, is that each layer is the 
result of the contraction and transformation of 
a preceding soft dark " passive" clot from which 
the serum has been gradually expressed, and 
whose corpuscles have disappeared by molecular 
degeneration. Another (Broca) is that it is 
formed by the gradual deposition of fibrin from 
the blood whipped out in the passage of the 
latter in its slow and irregular course along the 
surface ; the arrangement in layers is explained 
by temporary arrests of the process. 

Several weighty facts that have come into 
notice of late years militate strongly against the 
second theory. Thus, in a case reported by 
Wagstaife' a popliteal aneurysm which had 
been cured a few months before death by the 
use of Esmarch's bandage the sac (Fig. 351) 
was two inches long and one inch in diameter, 
and contained a central blood-clot measuring one 
by half an inch, surrounded by fibrous tissue 
which appeared to be the thickened wall of the 
artery and sac and contained blood-vessels. In 
this case the soft clot had produced no laminae. 
A similar case was reported by Reid in the 
Lancet, 1876, ii. p. 184, and in another, cured 
by the same means, an area of fluctuation, not 
pulsating, formed a day or two after the treat- 
ment, apparently due to the exuded serum of the 
clot ; it gradually disappeared and the cure was 
permanent. In other cases inflammation or irritation of the inner sur- 
face of the sac has been followed by diminution or cessation of pulsation 
and reduction in size of the aneurysm, apparently by the rapid deposi- 
tion of fibrinous layers ; and in other cases, in which death has followed 




Popliteal aneurysm cured by 
formation of a " passive" clot. 



" Eichet, Diet, de Med. et de Chir. pratiques, art. " Anevrysme." 
' Wagstaffe, Trans. London Path. Soc, vol. xxix. p. 72. 



^ Loc. cit. 



376 ANEURYSM. 

shortly after operative production of such irritation, the irritated parts 
have been found thickly coated by such layers. 

The behavior of the blood under other circumstances also indicates 
that simple slowing or arrest of the circulation does not lead to the pro- 
duction of such layers upon an unaltered arterial or vessel wall ; thus, 
after an artery has been tied in continuity or in an amputation the 
portion that lies between the ligature and the nearest proximal branch — 
a portion in which the blood is almost or quite stagnant — is habitually 
found uncovered by clot and often shrunk to a diameter much smaller 
than normal. Furthermore, in an old aneurysm partly occupied by 
laminated clots the extension of the endothelial layer of the intima over 
the surface of a portion of the clot appears to prevent subsequent forma- 
tion at those protected points. 

The theory, then, which seems most in harmony with the facts is, 
that the laminated clot is formed by slow repeated deposition from the 
blood under the provocation of some mechanical or chemico-vital condi- 
tion of the surface upon which the deposition takes place. 

So long as the tough laminated clot is adherent to the wall of the 
aneurysm, it partially protects it from the distending force of the blood, 
and thus checks the growth of the aneurysm ; but as its connection with 
the wall is not structural, as it is simply deposited upon it, and not 
bound fast to it by interlacing tissue, it may become detached in whole 
or in part by mechanical violence or change in shape, and to that extent 
cease to be protective. 

Of soft, dark (passive) clots much less is known from direct observa- 
tion : those that are found on the autopsy-table are doubtless formed 
after death or very shortly before, and of those that are formed during 
life by accident or treatment we can only infer the changes and relations 
from what is found at a later period and from what is known of the 
behavior of such clots elsewhere. We know that when an aneurysm 
ruptures and allows blood to escape into the adjoining tissues, the blood 
clots, and probably clots form more or less readily in the secondary 
pouches that sometimes are found in old aneurysms ; but it seems un- 
likely that large, soft clots form even in sacculated aneurysms unless 
the circulation in them is almost wholly arrested. "When they do so 
form, the natural shrinkage which they undergo by the escape of their 
serum must create a space into which the blood will again enter unless 
the orifice of communication or the artery itself has been plugged, so 
that only under exceptional circumstances can the formation of such a 
clot arrest the progress of the affection. In the cases in which cure has 
followed temporary arrest of the circulation, as by compression or the 
use of Esmarch's bandage, it is probable that the "artery itself has been 
occluded by the clot and has remained impervious. The cases referred 
to above of cure by the use of the Esmarch bandage indicate that under 
such circumstances the expressed serum of the clot is absorbed by the 
adjoining tissues, the sac shrinks and thickens as the clot grows smaller, 
and the artery is permanently occluded by the growth of granulations 
from its wall into the obstructing portion of the clot that has extended 
into it. 

The influence of an aneurysm upon the circulation in the vessels 
beyond it depends upon a number of variable conditions, such as the 



THE COMMON CIRCUMSCRIBED ANEURYSM. 



2,11 



position, size, and shape of the aneurysm (for the arterial circulation) 
and its pressure upon venous trunks (for the venous and capillary cir- 
culation). In considering the effect upon the arterial circulation the 
aneurysm is to be regarded as an elastic reservoir into which the blood 
brought by the proximal portion of the artery is temporarily diverted, 
with the consequent diminution and retardation of the cardiac ven- 



FiG. 352. 



8.V. 



Fig. 353. 





C.N. 



a An. 



JJi B? 



Half-diagrammatic, sliowing retardation of 
pulse in an aneurysm near tlie heart 
{An. 1) and in one far from the heart 
(An. f!) (Miohaux). 



Showing the retardation and reduction of 
volume of the pulse in the right carotid 
(C An) and right radial {R. d) as com- 
pared with that in left carotid (C. N.) and 
left radial (E. g), in a case of innominate 
aneurysm (Micnaux). 



tricular impulse in the distal portion and branches. The sphygmo- 
graphic trace on the artery below the aneurysm shows, therefore, a 
primary elevation that is retarded, less abrupt, and less high than that 
of the corresponding artery of the other limb, and the dicrotic rise on 
the descending trace is less marked or absent ; in other words, the distal 
stream is more steady, the variations of intra-arterial pressure and arte- 
rial expansion due to the cardiac systole and diastole are slighter than 
under normal conditions. The physical conditions and effect are similar 
to those of the common atomizer or force-pump, in which a compressed 
body of air transforms an intermittent impulse into a constant one and 
produces a steady stream. The effects upon the venous and capillary 
circulation are the ordinary ones of obstruction to the venous flow when 
the aneurysm is so large and so situated as to make pressure upon an 
important venous trunk. 

The tissues and organs adjoining an aneurysm may undergo import- 
ant changes in consequence of its presence and pressure ; those that are 
movable are pushed back by it as it grows, and those that are or become 
immovable ultimately undergo molecular absorption, gangrene, or ulcera- 
tion. Thus, veins are first occluded by pressure, and then obliterated 
by adhesion of their walls ; overlying bones, notably the ribs, sternum, 
and bodies of the vertebrae in the case of aortic aneurysm, gradually dis- 
appear at the points of pressure, evidently by a rarefying osteitis ; over- 
lying skin or the wall of an adjoining cavity, such as the oesophagus or 
the trachea, becomes adherent to the sac, then thinned, and is finally per- 
forated by ulceration or gangrene which involves the sac and leads to a 
usually fatal hemorrhage. 



378 



ANEURYSM. 



Fig. 354. 




More remote changes may follow in consequence of the Interference 
with the circulation by pressure on the veins or the plugging of the artery 

at the aneurysm, or of the detachment 
of larger or smaller portions of clot, 
which are then swept out by the blood 
and lodged as emboli at distant points. 
Grangrene of a portion of the limb 
below the sac may be caused by the 
mechanical interference with the venous 
return occasioned by the size of the 
aneurysm or by emboli coming from its 
interior, especially in the old. Emboli 
of small size are sometimes found after 
death under circumstances that indicate 
that they have done little or no harm ; 
in other cases rough manipulation of 
an aortic aneurysm has been followed 
immediately by convulsions and death, 
and the autopsy has shown the brain, 
liver, and kidneys studded with emboli 
in their smaller arteries, evidently de- 
tached by the handling. One such case 
occurred under my observation. 

Aneurysm of the thoracic .aorta, eroding "FJnallv inbcntunpnim riintnrp of 
vertebra; and ribs ; front of sac removed J- mauy, bUUCUUlueoUfc, luptuie Ol 

tpshowvertebraibodies (Froinaprepara-the sac may occur, and if the aneur- 

tion m Charing Cross Hospital Museum.) . •' , ' i i i i 

ysm IS upon a large artery the blood 
may escape into the adjoining tissues or cavity (peritoneal, pleural) in 
quantity sufficient to cause death within a short time or immediately ; 
if, on the other hand, the artery or the rupture is small, the bleeding is 
soon stopped by the pressure of the parts and the clotting of the escaped 
blood. There are some facts to indicate that a well-defined wall con- 
tinuous with that of the aneurysm may form about such escaped blood 
and constitute a pouch or secondary aneurysm, but it seems probable that 
such rupture, occurring in the later stages of the evolution of the sac, 
would be the precursor of other similar ones, and that the patient would 
seldom survive the accidents long enough to permit the formation of 
such protective conditions. 

Symptoms and Course. — Subjective symptoms of an aneurysm are 
mainly due to its pressure upon other parts, and consequently seldom 
appear before it has gained considerable size : then the patient experi- 
ences more or less constant pain, dull and aching or neuralgic, a sensation 
of weight or weakness in an affected limb, or dyspnoea or dysphagia if 
the affection involves the thoracic aorta ; in intracranial aneurysms he is 
conscious of a persistent murmur or bruit. 

The objective signs are those of a well-defined, elastic, fluctuating, 
usually pulsating tumor, unaccompanied, at least at first, hj inflamma- 
tory symptoms. It may be at first recognized by chance, or the patient's 
attention may be called to it by vague sensations or by a feeling as if 
something had given way or was increasing rapidly and making pressure. 
If the tumor is so situated that it can be distinctly palpated in its earlier 
stages, it appears smooth and regular in outline, globular or ovoid, rarely 



THE COMMON CIRCUMSCRIBED ANEURYSM. 379 

smaller than a cherry or larger than an orange, in consistency like a not 
very tense cyst, and capable of reduction in size by broad uniform pres- 
sure upon the tumor itself or by compression of the artery above it, with 
immediate return to its original size when the pressure is removed : when 
the hand is placed upon it distinct pulsation corresponding to that in the 
arteries is felt, and if it is grasped between the thumb and finger placed 
on its sides, the pulsations will be equally well felt and will slightly 
separate the fingers at each stroke — " expansile pulsation." The finger 
may at the same time feel a distinct vibrating thrill, but this phenome- 
non, constant in arterio-venous aneurysm, is rare in the form now under 
consideration. Auscultation reveals the aneurysmal bruit or nmrmur, 
usually soft or blowing, sometimes harsh and rasping. It has been 
attributed to vibration of the borders of the orifice of the surface occa- 
sioned by the current of blood, but seems more probably due to waves 
created by irregularities of pressure : similar sounds can be produced by 
pressure with a stethoscope upon an artery, a vein, or even upon a rub- 
ber tube through which water is flowing. 

Diminution of the force and volume of the pulse in the artery or its 
branches beyond the aneurysm, when compared with the corresponding 
vessels of the other side of the body, is generally recognizable by touch ; 
its slight retardation by a fraction of a second can be demonstrated by 
the sphygmograph. 

The tendency of an aneurysm is clearly toward increase in size and 
ultimate rupture, but the increase takes place with varying rapidity and 
is occasionally arrested for longer or shorter intervals. Spontaneous 
cure, in the sense of permanent or very prolonged arrest of growth, 
reduction in size, and cessation of pulsation and murmur, is sometimes 
observed ; it will be subsequently considered in detail. The rate of 
growth appears ordinarily to be slowest in fusiform aneurysms, but 
changing conditions of the sac and its contents may result in marked 
retardation or long arrest of growth of even a rapidly-growing saccu- 
lated one : such conditions are the deposition of fibrinous layers upon 
the wall, or, apparently, the formation of a large soft clot which occludes 
the orifice. The effect of fibrinous layers is well shown in cases treated 
by distal ligation of some of the branches of the artery : the artery 
remains pervious, blood continues to flow through it and the sac, but 
the latter shrinks and does not again increase. At the autopsy it is 
found to be lined throughout by fibrinous clots having a smooth shining 
surface. The process appears to be — deposition of the layers and shrink- 
ing of the sac in consequence of the diminution in the force and volume 
of the stream ; then gradual spread of the endothelium over the surface 
of the layers, by which their edges are fastened down and their surface 
is made more like that of the normal intima. Similar circulatory con- 
ditions (and consequent results) may be produced spontaneously, as by 
detachment of a clot and plugging of distal branches. 

The increase in size may be uniform, the aneurysm retaining its 
shape and consistency and simply growing larger, or it may be more 
marked at some points than at others, and the tumor is then usually softer 
at such places ; the pulsation may change in force from time to time, 
and the murmur cease or change in character. The subjective symptoms 
— pain, sense of weight, etc. — increase, and special ones may be added 



380 ANEURYSM. 

by implication of special organs, as in thoracic or abdominal aneurysm. 
Pressure-symptoms increase or are added; the limb or face becomes 
cedematous or passively congested by venous obstruction ; the voice may 
be altered by pressure upon the recurrent laryngeal nerve ; dyspnoea 
may be caused by pressure upon the lung or trachea or bronchus ; severe 
pain, by the stretching of a nerve or by osteitis set up in the vertebrae, 
ribs, or sternum. As the skin is approached it becomes permanently 
discolored, then adherent to the sac, and breaks down by sloughing or 
ulceration. Growth in other directions may effect a similar change in 
other hollow organs, such as the trachea, oesophagus, pericardium, pleura, 
or peritoneum, or rapid growth at one point may lead to rupture of the 
sac, with escape of blood into the surrounding tissues, and consequent 
formation of a haematoma or " diffuse secondary aneurysm." Such a 
rupture may, under suitable conditions, be recognized by the rapid 
formation of a swelling that is usually ill-defined and without pulsation 
or bruit. If the flow of blood through the sac is not too profuse and 
continuous, a fairly well-defined wall may form about it, continuous with 
the primary sac and practically forming part of it ; the swelling then 
becomes more defined and pulsation and bruit may appear in it. 

Slight transient inflammation of the sac or adjoining parts, as indi- 
cated by tenderness, and perhaps by redness and oedema of the overly- 
ing skin, is not infrequent; acute inflammation going on to suppuration 
is rare and very dangerous. Such acute inflammation has been observed 
under circumstances that indicated that it was caused by sudden clotting 
of the blood within the sac, but Broca's statement that such clotting was 
very likely to lead to such a result has proved to be an exaggeration. 
The occurrence of this complication is marked by notable local changes 
and constitutional reaction : the tumor ceases to pulsate, the overlying 
parts become swollen, red, painful, and throbbing, as in other acute 
inflammations, and the patient is feverish and may have rigors or even 
a sharp chill. The subsequent course is that of an abscess, and danger- 
ous hemorrhage may ensue. Exceptionally, the plugging of the orifice 
and of the artery may be permanent, and the process may end in the 
cure of the affection. A similar process may be the result of suppu- 
ration originating in the adjoining tissues outside the sac. 

Inflammation of the aneurysm when it is situated upon the main 
artery of a limb is very liable to be followed by gangrene of the distal 
portion, because of the interference with the arterial supply by clotting 
and with the venous return by pressure. 

Eupture of the aneurysm through the skin or into some cavity of the 
body is an extremely grave accident. The resultant hemorrhage may be 
profuse and promptly fatal : if small or if arrested by clotting, it is soon 
repeated, and a fatal termination can only be prevented when it is possible 
to secure the artery above the aneurysm. 

Spontaneous Cure. — Mention has already been made of the fact that 
sometimes aneurysms spontaneously diminish in size, even to the point 
of disappearance, lose their pulsation, and are, in fact, permanently 
cured. As the processes by which this arrest or cure is effected have 
furnished the principles upon which the treatment of aneurysm has been 
largely based, they deserve separate consideration. The cure may be 
effected either by the continuous deposition of laminated clot or by the 



THE COMMON CIRGUMSCRIBED ANEURYSM. 381 

sudden clotting of all the blood in the sac, and either of these processes 
may be the result of a variety of circumstances. Thus, we have seen 
that the deposit of layers of fibrin upon the wall is apparently the result 
of slowing of the stream or of change in the character of the inner 
surface of the sac, and possibly also of change in the character of the 
blood ; consequently, anything which produces these changes may exert 
a favorable influence upon the progress of the affection, and may even 
arrest it permanently. In like manner, the sudden clotting of the blood 
in the sac may be excited by important changes in the wall or by plug- 
ging of the orifice of the aneurysm or of the artery above or below the 
orifice. 

The influence of change in the character of the blood is shown by 
those cases in which arrest of growth has taken place during serious 
acute diseases. Barwell quotes one of a subclavian aneurysm cured 
during an attack of enteritis, and one of the femoral during an attack 
of acute rheumatism, and the many cases of improvement and some of 
cure by the internal administration of drugs thought to increase the 
coagulability of the blood, combined with rest and low diet, might be 
quoted also in illustration, although in all these cases the quieting efi^ect 
upon the circulation of the enforced confinement to bed must be taken 
into account. 

The slowing of the circulation as a factor may be either general or 
local. Absolute quiet in bed, combined with a low and unstimulating 
diet, cardiac sedatives, and sometimes venesection, has long been recog- 
nized as a potent aid in the treatment of internal aneurysms not suitable 
for surgical interference. The influence is most marked in sacculated, 
pouched aneurysms (as compared with fusiform), and probably the main- 
tenance of the recumbent position has a notable effect upon the circu- 
lation within such an aneurysm for physical, mechanical reasons, even 
when it has little or none upon the general circulation. 

Slowing of the circulation within the sac itself must depend upon a 
variety of conditions, such as the size of the orifice, the shape of the sac, 
the pressure of clots ; and doubtless the blood in every aneurysm varies 
greatly in its rate of movement and change in different parts of the sac 
and at different times. There is reason to suppose that portions of clot 
sometimes become detached from the wall and lodge in the orifice, thereby 
greatly checking the flow of blood through it, and thus effect a cure, or 
that a similar condition is produced by the growth of a clot at the edge 
of the orifice. Probably a complete clot formed within some well-defined 
pouch may, under favoring conditions, increase rapidly and fill the entire 
sac. A piece of laminated clot detached from the wall and carried out 
into the artery by the blood may lodge in the artery a short distance 
below, usually at a bifurcation, and either reduce the amount of blood 
that passes through the vessel, and thus slow the circulation in the aneur- 
ysm, or obstruct the vessel entirely, either immediately or by its subse- 
quent increase in size, and thus arrest the stream and lead to the forma- 
tion of a large soft clot that fills the aneurysm and the artery below it. 

It has been claimed that a sacculated aneurysm has itself in some 
cases occluded the artery by pressure upon it above or below the orifice, 
but the alleged cases are not demonstrative. 

Where the inner surface of the sac is smooth and lined with endothe- 



382 ANEURYSM. 

Hum the tendency to the formation of laminated clot is slight or absent ; 
but where such a protective surface is not present, as in sacs of rapid 
growth, the deposit is favored ; and when rupture takes place the blood 
that has escaped into the adjoining tissues appears to be prone to clot in 
bulk, and such a clot may be the starting-point of one that will fill the 
aneurysm entirely. To a still greater degree an inflamed sac is favorable 
to the complete clotting of the blood and to the cure of the aifection, if 
the patient does not perish by hemorrhage or if the resulting interference 
with the venous flow does not lead to gangrenous changes that necessitate 
amputation. A few cases have been reported in which such inflamed 
sacs have ruptured externally, with discharge of clots and liquid blood, 
and the patients have recovered ; but the accident is full of danger. 

Occasionally aneurysms that have long remained quiescent, apparently 
cured, begin again to increase in size : such rarely pulsate or have a 
bruit, and they probably receive their blood by a recurrent flow through 
the distal portion of the artery. 

Diagnosis. — The diagnosis of an aneurysm that is developing in the 
usual manner, and has not undergone any of the important complicating 
changes above mentioned, and which is accessible to inspection and pal- 
pation, is usually easy. The well-defined outline of the tumor, its con- 
sistency, expansile pulsation and murmur, and its position on the course 
of an artery are all readily recognizable, and in addition we have its 
steady, rather rapid growth, the absence of the signs of inflammation, 
the diminution in size when the artery is compressed above it, its sphyg- 
mographic trace, and the diminution of pulsation and the change in the 
sphygmographic trace of the artery below it. On the other hand, aneur- 
ysms in the thorax or abdomen or at the root of the neck may be wholly 
inaccessible to palpation, or so slightly so as not to afford positive diag- 
nostic signs, and those of the limbs may have undergone changes or com- 
plications that abolish or mask such signs. Furthermore, other affections 
may resemble aneurysms quite closely. Many errors of diagnosis, some 
of them disastrous in their results, have been made, such as mistaking a 
rapidly -growing aneurysm for an abscess or a shrunken, quiescent one 
for an enlarged lymphatic gland ; but, as Mr. Barwell says, the greater 
number of these disasters have been due to insuiflcient caution — to resort 
to the knife without having made a careful examination ; and he calls 
attention again to the importance of a strict observance of the old rule, 
which forbids the opening of any swelling in the course of or over a 
large artery without a previous thorough search for the signs of aneurysm. 
The same caution should be used in the case of swellings on the front of 
the chest. 

The difficulties in diagnosis arise from the fact that some aneurysms 
present few of the characteristic signs of the affection, and, on the other 
hand, that tumors of an entirely different character may present some 
of them. Of the characteristic signs, pulsation and bruit are those 
whose presence in other affections or whose absence in aneurysm is most 
likely to mislead. As we have seen, they are absent when the aneurysm 
is consolidated or when the artery supplying it is occluded or compressed, 
and they may be absent or so slight as to be recognized only with great 
difficulty if the aneurysm is widely ruptured or if the surrounding parts 
are much inflamed and swollen. The diagnosis must be made by the aid 



THE COMMON CIRCUMSCRIBED ANEURYSM. 383 

of the history, and possibly by change in the pulse in the distal branches 
of the artery. If the condition permits of delay in order to Match the 
subsequent progress of the case, the diagnosis may become clear, for con- 
solidated aneurysms do not increase in size, while malignant tumors do. 

Pulsation is the symptom which is most likely to lead the surgeon to 
mistake a tumor of another character for an aneurysm. Such pulsation 
may be due to the vascularity of the tumor itself or may be communi- 
cated to it from an underlying artery. Tumors which possess a pulsation 
of their own are (in addition to other forms of aneurysm than those 
now under consideration, such as arterio-venous and cirsoid aneurysms) 
certain very vascular carcinomata and sarcomata, especially certain ones 
of bone. The diagnosis in such cases must be made by attention to the 
character of the pulsation, which is more distinctly expansile in aneur- 
ysm, to the absence of fluctuation in vascular tumors, and to their 
slighter loss of bulk when the afferent artery is compressed. In the 
bone-tumors careful examination may show change in the shape of the 
bone and the presence of bony outgrowths or plates in the wall of the 
tumor near its base. 

Tumors, solid or liquid, overlying an artery and receiving pulsation 
from it may be recognized by the absence of expansion and of shrinkage 
when the artery is compressed, and by the cessation of the pulsation 
■when the tumor is lifted up from the artery. It must be borne in mind 
that the pulsation communicated to a solid tumor may seem to be expan- 
sile when the palpating fingers cannot be pressed down to its equator : as 
the tumor is lifted at each beat a wider portion is pressed in between the 
fingers and separates them exactly as expansile pulsation does. A 
murmur may be present in vascular tumors or when a solid or liquid 
tumor presses upon an artery. 

Prognosis. — This is always serious, although the actual danger to life 
or limb may vary greatly in different cases and at different periods in the 
same case. In general terms, the nearer to the heart the greater the 
danger to life. Except in the comparatively rare cases of spontaneous 
cure, the progress is steady toward ultimate rupture, and the larger the 
vessel the more certain is such a rupture to lead to a fatal hemorrhage, 
and the smaller is the prospect of being able to arrest the progress by 
treatment. 

Treatment. — The treatment of aneurysm may be medical or surgical. 
The former term is applied to that method which seeks to effect a cure 
by rest, diet, and internal medication ; the latter includes all other 
methods in which some external agent is brought to bear upon the 
aneurysm, its contents, or the artery upon which it is developed. 

The medical treatment of aneurysm, first systematized by Valsalva 
and more recently brought into prominence by Mr. Joliffe Tufnell, ^ 
seeks to promote the processes of spontaneous cure by the deposition of 
laminated fibrin, by quieting the heart-action, and by increasing the co- 
agulability of the blood. The main agents in this attempt are prolonged 
absolute rest in the recumbent position, restriction of food and drink 
almost to the minimum necessary for the support of life, the internal 
administration of certain drugs, and sometimes venesection. The method 
has been employed exclusively for internal aneurysms and those in which 

' Tufnell, The Successful Treatment of Internal Aneurysms, 1864. 



384 ANEURYSM. 

operative methods were contraindicated. It requires much resolution 
and fortitude on the part of the patient to continue the treatment for the 
necessary length of time, seldom less than six weeks. 

The details, as given by Barwell, are — absolute confinement to bed 
and one of the two following systems of diet, known as the " low " and 
the "dry." The "low" diet consists of bread, 10 ounces; butter, 1 
ounce ; rice or tapioca pudding, 6 ounces ; milk, 1 pint — divided into 
three or four meals ; once or twice a week a little fish or boiled meat 
may be added if the patient becomes restless under the deprivation. The 
" dry " diet is as follows : for breakfast and supper, bread, 4 ounces ; butter, 
^ ounce ; milk, 2 ounces ; for dinner, meat, 3 ounces ; bread, 3 ounces ; 
water or milk, 3 ounces. The return to ordinary diet at the end of 
treatment must be gradual. Barwell thinks that venesection at the 
beginning of the treatment, and perhaps repeated during it, would be 
advantageous ; and Holmes says its moderate use " appears both rational 
and, as far as we can judge from recorded cases, successful." 

The drugs used are belladonna, hydrocyanic acid, aconite, and ver- 
atrum to reduce the heart-action, and bromide of potassium to control 
pain and irritation. Acetate of lead and iodide of potassium have also 
been used, especially the latter, but without demonstrated benefit. Flint' 
reported a case of aneurysm of the abdominal aorta which was appa- 
rently cured by the use of the chloride of barium in doses of from one- 
fifth to two-fifths of a grain three times daily for about five months, 
after Tufnell's method had failed. The most rapid improvement coin- 
cided with the smaller dose. 

Surgical Treatment. — The history of the surgical treatment of aneur- 
ysm is mainly the story of the invention and application of a great 
variety of measures designed to diminish the risk to life involved in the 
efibrt to accomplish one of two results — the evacuation of the sac and 
the abolition of its connection with the artery, or the obliteration of its 
cavity by " active " or " passive " clots. With few exceptions the imme- 
diate object of the different operations has been to initiate or promote 
the processes of spontaneous cure, and the stimulus to the introduction 
of new methods in such numbers and variety has been found in the risk 
to life, or the uncertainty of result, or the inapplicability to certain 
aneurysms of those previously in use. The great advance made in 
recent years in securing the prompt and easy healing of surgical wounds 
has practically deprived most of these methods of all but an historical 
interest ; and, curiously enough, the operative method which has most 
recently received the stamp of approval and has been put forward as 
the method of choice is practically the one that stands at the other end 
of the long list — the one employed and described in the second and 
third century A. D. by Antyllus. 

According to Broca,^ to whose thorough search and exceptional oppor- 
tunities we are indebted for our knowledge of the early history of the 
subject, the art of surgery previous to the time of Antyllus acknowledged 
itself powerless to treat aneurysms. The affection was known to be 
dangerous, its gravity was attributed to noxious elements in the blood 
contained in the tumor, and doubtless attempts had been made to relieve 

' Flint, Practitioner, 1879, vol. xxiii. p. 31. 
' Broca, Des Anlvrysfnies, Paris, 1856. 



THE COMMON CIRCUMSCRIBED ANEURYSM. 385 

by evacuating the blood. What the consequences of such attempts were 
it is easy to imagine, and until some less dangerous remedy could be 
found it is plain that abstention must have been the rule. Of the 
writings of Antyllus upon the subject we possess only what has been 
preserved through quotation by others, especially by Oribasius, who, 
writing in the fourth century A. D., quoted among others his chapter 
upon aneurysm. The forty-fifth book of Oribasius, in which this quo- 
tation occurs, was long supposed to have been lost, and was only found 
about 1825 among other Greek manuscripts in the Vatican. After 
describing two kinds of aneurysm (apparently our spontaneous and 
arterio-venous), he says : " It is not right to abandon all aneurysms to 
their fate, as the ancient surgeons taught, but it would be extremely 
dangerous to operate on all. So we abstain from touching aneurysms 
of the axilla, groin, and neck, both because of the size of the vessels 
and of the impossibility or extreme difficulty of ligating them. We also 
do nothing for very large aneurysms, in whatever part of the body they 
may be. We operate upon aneurysms of the extremities, the limbs, and 
the head in the following manner." He then describes the operation by 
a straight incision along the course of the vessel, the exposure of the 
aneurysm, the drawing aside of the vein, and the placing of a ligatur^ 
upon the artery above and below the sac. The latter is then opened by 
a small incision and " its contents evacuated without danger of hemor- 
rhage." 

According to Broca's translation, it would seem that Antyllus dis- 
sected the aneurysm entirely free from end to end, but this appears to 
be not only intrinsically improbable, but also not in harmony with the 
rest of the description. Whatever the reason may have been — difficulty 
of execution, secondary hemorrhage, or the general lowering of the 
intellectual level — we find the operation restricted in the fifth century 
to aneurysms at the bend of the elbow (with the interesting addition of 
preliminary double ligation and intermediate division of the brachial 
artery two or three inches below the axilla — Aetius) and wholly aban- 
doned a few centuries later. With the Renaissance it again appeared in 
its original form — ligature above and below, incision of the sac — but 
still restricted to aneurysms at the bend of the elbow : the invention of 
the tourniquet in 1674 made its execution easier and encouraged surgeons 
occasionally to extend its application to other aneurysms; but, on the 
other hand, the discovery of the circulation of the blood checked its use, 
through the fear of causing gangrene of the limb by cutting off" the 
supply of the blood, and led to a variety of attempts to secure, after 
incision of the sac, the closing of the opening into the artery without 
ligating the latter. In the mean time (1710), Anel, a French surgeon 
living in Rome, operated upon a large aneurysm at the elbow, due to an 
unskilful venesection, by tying the artery only above and without opening 
the sac. In the reasons which he gave for thus departing from the usual 
practice he says he was confident that the blood contained in the sac 
would flow out through the distal part of the arter\', that the sac once 
emptied would not fill again, that its avails would shrink and the tumor 
would disappear ; " which did not fail to take place as I had anticipated." 
Although Anel's operation gave rise to an acrimonious discussion and 
was repeated two or three times with success, it had no lasting effect upon 

Vol. II.— 25 



386 ANEURYSM. 

practice, and was soon forgotten, and until the latter part of the eigh- 
teenth century the only direct method of treatment in use appears to 
have been the old operation of opening the sac and tying the vessels that 
opened into it. The results were so bad that even this appears to have 
been but rarely resorted to, most surgeons preferring amputation, at least 
in the case of popliteal and femoral aneurysms. It is true that direct 
compression of the tumor had been occasionally employed from the 
earliest times and had furnished a few notable successes, but there was 
nothing in its record, no constancy in its action, no underlying principle, 
to give it any standing as a reasonable mode of treatment. As we now 
understand it, its few successes were in part in traumatic aneurysms in 
which the wound in the artery had time and opportunity to heal, and in 
part, probably, in cases in which an intercurrent or consequent inflam- 
mation of the sac produced a cure. 

In 1673, Genja had successfully healed a wound of the brachial artfiry 
at the elbow by compression of the vessel above, and his example had 
been followed in several cases, but it was not until 1765 that the plan 
was applied in the treatment of aneurysm. In that year Guattani, a 
surgeon at Rome, cured a popliteal aneurysm by prolonged compression 
of the femoral artery by means of a long pad and a circular bandage. 
His idea appears to have been merely to diminish the amount of blood 
coming to the sac, not to interrupt the stream entirely, for he feared gan- 
grene of the limb if the latter should be done. He repeated it in several 
cases, generally with success, and his example was followed by others ; 
and it seems probable that the method would have been generally accepted 
had not proximal ligation of the artery at some distance above the sac 
been introduced shortly afterward. Notwithstanding the immediate success 
attending the latter, co